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POLICY POINTS: Looking for a way to curtail market power abuses in health care and rein in prices, 20 states have restricted most‐favored‐nation (MFN) clauses in some health care contracts. Little is known as to whether restrictions on MFN clauses slow health care price growth. Banning MFN clauses between insurers and hospitals in highly concentrated insurer markets seems to improve competition and lead to lower hospital prices. CONTEXT: Most‐favored‐nation (MFN) contract clauses have recently garnered attention from both Congress and state legislatures looking for ways to curtail market power abuses in health care and rein in prices. In health care, a typical MFN contract clause is stipulated by the insurer and requires a health care provider to grant the insurer the lowest (i.e., the most‐favored) price among the insurers it contracts with. As of August 2020, 20 states restrict the use of MFN clauses in health care contracts (19 states ban their use in at least some health care contracts), with 8 states prohibiting their use between 2010 and 2016. METHODS: Using event study and difference‐in‐differences research designs, we compared prices for a standardized hospital admission in states that banned MFN clauses between 2010 and 2016 with standardized hospital admission prices in states without MFN bans. FINDINGS: Our results show that bans on MFN clauses reduced hospital price growth in metropolitan statistical areas (MSAs) with highly concentrated insurer markets. Specifically, we found that mean hospital prices in MSAs with highly concentrated insurer markets would have been $472 (2.8%) lower in 2016 had the MSAs been in states that banned MFN clauses in 2010. In 2016, the population in our sample that resided in MSAs with highly concentrated insurer markets was just under 75 million (23% of the US population). Hence, banning MFN clauses in all MSAs in our sample with highly concentrated insurer markets in 2010 would have generated savings on hospital expenditures in the range of $2.4 billion per year. CONCLUSIONS: Our empirical findings suggest banning MFN clauses between insurers and providers in highly concentrated insurer markets would improve competition and lead to lower prices and expenditures.

Policy Points The focus of successful aging is on the social contexts that enable individuals to be productively engaged and secure, with an emphasis on equity. There is currently no index to measure progress towards this goal at the US state level. We developed an empirical index for the evaluation of US state adaptation to societal aging across five critical domains that support successful population aging: (1) productivity and engagement, (2) security, (3) equity, (4) cohesion, and (5) well-being. Our index shows substantial variability over time and is not overly influenced by the performance of an individual domain. This suggests that it can be used to monitor state progress over time toward the goal of supporting successful aging. Rather than a major national trend, there are large between-state differences and changes in our index over time. This suggests individual US state policies and programs, as well as local economic conditions, may have a substantial impact on adaptations to societal aging. Context Although it is recognized that aspects of US state environments impact the likelihood that older adults age successfully, there is currently no reliable and comprehensive measure of contexts that best support successful aging at a state level. The current project adapts a multidimensional index previously used to assess adaptation to successful aging in developed countries and applies it to the 50 US states and the District of Columbia. Methods We obtained data from multiple sources for all 50 US states and the District of Columbia from 2003 to 2017 in order to measure five distinct domains that define successful population aging: (1) productivity and engagement, (2) security, (3) equity, (4) cohesion, and (5) well-being. We created a ranking of states for the year 2017 based on these domains, and also examined how individual US state rankings changed over time from 2003 to 2017. Findings The level of adaptation to successful aging varied substantially between states and over time. The highest-ranked states in 2017 were Vermont, Hawaii, Iowa, Colorado, and New Hampshire, and the lowest-ranked states were Louisiana, Arkansas, Kentucky, West Virginia, and Mississippi. Mississippi, South Carolina, Iowa, Arizona, and Delaware had the greatest improvement in their ranking over the period of 2003 to 2017. Our findings were generally robust to the weighting scheme used and were not overly influenced by any particular domain. Conclusions The US State Index of Successful Aging can be used to monitor US state progress in promoting the well-being and health of aging populations. Factors driving the changes in the index remain to be elucidated.

POLICY POINTS: Pharmaceutical trade organizations and media outlets in the United States regularly point to compulsory licensing—or even its threat—as the mechanism that peer countries use to control the price of prescription drugs. Our comparative analysis shows that compulsory licensing is not frequently employed in high‐income countries outside the United States as a direct response to drug prices. When its use is threatened, a license is rarely issued and even less often does it lead to a price discount. Accordingly, compulsory licensing is unlikely to contribute to price discrepancies between the United States and other developed nations. In fact, of the 21 compulsory licensing petitions we identified outside the United States, over one‐third were made by pharmaceutical companies themselves and only three were threatened by a government authority. CONTEXT: Compulsory licensing is a practice whereby national authorities can license a third party to produce a patented product, such as a pharmaceutical drug, effectively enabling the production of a generic before the original patent expires. The policy was designed—and has historically been used—to improve access to essential medicines in low‐income countries and during public health crises. Although it was not intended to impact drug prices directly, the threat of compulsory licensing may indeed contribute to lower drug prices in high‐income countries outside the United States. Our study sought to determine the plausibility of this claim. METHODS: We compiled a comprehensive database of compulsory licensing episodes in the United States and 17 comparator nations over the 20 years following the 2001 Doha Declaration, and we recorded the motivation and outcome of each instance. Our search began with publicly available reports compiled by organizations specializing in pharmaceutical intellectual property, expanded to a query of legal proceedings in Westlaw, and concluded with a comprehensive literature review on PubMed. FINDINGS: This strategy yielded 45 unique episodes of compulsory licensing, 24 in the United States and 21 outside. A minority (24%) of petitions outside the United States were motivated by high prices, and in all countries, only three cases were clearly associated with a price discount. CONCLUSIONS: We found no evidence to suggest that compulsory licensing is either frequently threatened or successfully implemented by countries outside the United States to secure price discounts for the most expensive pharmaceuticals, those that are newly patented and just entering the market.

POLICY POINTS: Although immigration policy is recognized as a social determinant of health, less is known about how mechanisms, such as news coverage of policy, influence intermediary and proximal health processes like seeking health care. The extent of news coverage of federal, state, and local exclusionary or integration immigration policies can influence public agendas regarding immigrant inclusion and exclusion. Exclusionary federal immigrant policies have dominated the news across the United States over the past ten years, despite active immigrant integration policymaking at national, state, and local levels. CONTEXT: Immigration policymaking at federal, state, and local levels in the United States has proliferated in the past decade. While evidence demonstrates that immigration policy is a determinant of health, there has been limited examination of the mechanisms by which policy influences proximal health processes. News coverage has served as a central platform for debates over restrictive and inclusive immigration policies and may constitute an important health mechanism by shaping public agendas, influencing support for immigrant exclusion or inclusion, and framing policy issues, thereby influencing immigrants’ social climates. This study sought to examine the extent of news coverage of exclusionary and inclusive immigration policy at federal and state levels and variations in messages about immigrants during two periods of extensive policymaking. METHODS: We conducted a quantitative content analysis of newspapers’ coverage of immigration policy between 2010 and 2013 and between 2017 and 2019. We conducted a systematic NewsBank search of articles covering legislation, lawsuits, and other policies related to immigration (n = 931). Articles were coded for policy type and level, positive or negative framing of immigrants, and other characteristics. Our analysis then compared the patterns of the two periods. RESULTS: In both periods, the majority of coverage focused on exclusionary policies at the federal level, despite a significant increase in integration policies between 2017 and 2019. We found significant shifts in both the negative and positive framing of immigrants, from the dominant negative messages of immigrants as an economic drain to immigrants as criminals and the dominant positive messages of immigrants’ economic contributions to immigrants as families. CONCLUSIONS: Since 2010, coverage of exclusionary federal policy has consistently dominated the news, as messages have increasingly described immigrants as either criminals or part of families. We discuss the health implications and future research directions of news coverages’ role in influencing the immigration policy and social contexts that have been linked to health outcomes.

Policy Points Clarifications to Senate Bill (SB)1152 are necessary to address the differences between inpatient and emergency department (ED) discharge processes, determine how frequently an ED must deliver the SB1152 bundle of services to a single patient, and establish expectations for compliance during off-hours when social services are unavailable. Because homelessness cannot be resolved in a single ED visit, the state should provide funding to support housing-focused case workers that will follow patients experiencing homelessness (PEH) through the transition from temporary shelters to permanent supportive housing. Medi-Cal could fund the delivery of the SB1152 bundle of services to defray the costs to public hospitals that provide care for high numbers of PEH. California legislators should consider complementary legislation to increase funding for shelters so that sufficient capacity is available to accept PEH from EDs and hospitals, and to fund alternative strategies to prevent poverty and the upstream root causes of homelessness itself.ContextPrompted by stories of "patient dumping," California enacted Senate Bill (SB) 1152, which mandates that hospitals offer patients experiencing homelessness (PEH) a set of resources at discharge to ensure safety and prevent dumping.MethodsTo evaluate interventions to meet the requirements of SB1152 across three emergency departments (EDs) of a Los Angeles County public hospital system with a combined annual census of 260,000 visits, we used an explanatory sequential mixed methods approach, focusing first on quantitative evaluation and then using information from qualitative interviews to explain the quantitative findings.FindingsIn total, 2.9% (1,515/52,607) of encounters involved PEH. Documentation of compliance with the eight required components of SB1152 was low, ranging from 9.0% to 33.9%. Twenty-five provider interviews confirmed support for providing assistance to PEH in the ED, but the participants described barriers to compliance, including challenges in implementing universal screening for homelessness, incongruity of the requirements with the ED setting, the complexity of the patients, and the limitations of SB1152 as a health policy.ConclusionsDespite operationalizing universal screening for homelessness, we found poor compliance with SB1152 and identified multiple barriers to implementation.

POLICY POINTS: While the coronavirus pandemic has underscored the important role of public health systems in protecting community health, it has also exposed weaknesses in the public health infrastructure that stem from chronic underfunding and fragmentation in delivery systems. The results of our study suggest that the public health system structure can be strengthened through the targeted implementation of high‐value population health capabilities. Prioritizing the delivery of value‐added population health capabilities can help communities efficiently use limited time and resources and identify the most effective pathways for building a stronger public health system and improving health outcomes over time. CONTEXT: While the novel coronavirus pandemic has underscored the important role of public health systems in protecting community health, it has also exposed weaknesses in the public health infrastructure that stem from chronic underfunding and fragmentation in public health delivery systems. Information about the relative value in the implementation of recommended population health capabilities can help communities prioritize their use of limited time and resources and identify the most effective pathways for building a stronger public health system. METHODS: We used a longitudinal cohort design with data from the National Longitudinal Survey of Public Health Systems to examine longitudinal and geographic trends in the delivery of population health capabilities and their impact on system strength across communities in the United States. We used linear probability models to ascertain whether the delivery of certain capabilities added value to public health system strength. FINDINGS: Those communities with the strongest classification of public health system structure in both urban and rural areas implemented the largest set of population health capabilities. Results from the linear probability model indicate that a set of population health capabilities are associated with increased public health system strength. Key activities include allocating resources based on a community health plan, surveying the community for behavioral risk factors, analyzing the data on preventive services use, and engaging community stakeholders in health improvement planning (p < 0.01). CONCLUSIONS: The results of this study suggest that public health systems can be strengthened through the targeted implementation of high‐value population health capabilities. Prioritizing the delivery of value‐added population health capabilities may help communities increase their public health system's capacity and improve health outcomes.

POLICY POINTS: In low‐income communities in the South Bronx and Puerto Rico, Puerto Rican youth are exposed to many of the same risk and protective factors for developing depression, anxiety, or psychological distress; yet it is unclear how the ethnic minority context of the South Bronx and ethnic majority context of Puerto Rico influence risk. Results from our quasi‐experimental, longitudinal study demonstrate the importance of addressing social factors (parent‐child relationships, youth peer relationships) for youth living in the majority context, and neighborhood and cultural factors (residential mobility, perceived discrimination, perceived social position in the neighborhood) for youth living in the minority context. Our findings support the need for tailoring programs specific to the needs of youth who reside in an ethnic majority or a minority context, since some of the risk factors might operate differently depending on context. Housing and neighborhood environment policies that address discrimination and eliminate structural inequities for ethnic minority groups may protect against the harm of minoritization on young people's mental health. CONTEXT: Puerto Rican youth growing up in low‐income communities in the South Bronx and Puerto Rico are exposed to many of the same risk factors for major depressive disorder, generalized anxiety disorder, and psychological distress. One potentially powerful factor differs: Puerto Ricans have been socially marginalized as an ethnic minority group in the South Bronx, but are the ethnic majority of the population in Puerto Rico. A growing body of literature demonstrates the influence of neighborhood, cultural, and social factors and parental psychopathology in the development of mental health problems. An important unanswered question is whether these risk and protective factors have the same impact for youth raised as members of an ethnic majority versus minority group. METHODS: Using a population‐based cohort study, with four waves of assessment from early childhood into young adulthood, we investigated whether ethnic minority context alters risk and protective factors for depression, anxiety, and psychological distress. Our longitudinal data set includes 2,491 young children at baseline (82.8% retained at wave 4). Using a quasi‐experimental design, we examine how ethnic minority context can alter the development of mental health disorders as Latinx children transition to late adolescence and young adulthood. FINDINGS: Some risk and protective factors operated differently across minority and majority contexts. Higher discrimination and social position were more powerful risk and protective factors, respectively, in the minority context, whereas positive peer relationships mattered more in the majority context. Children of mothers with depression were significantly more likely to develop anxiety in late adolescence and young adulthood in the majority context (60.0%) compared to the minority context (4.5%). CONCLUSIONS: Preventing depression and anxiety disorders in Latinx young adults may require targeting different childhood factors depending on whether they reside within the ethnic majority or minority context. People in the ethnic minority context may benefit more from policies aimed at reducing discrimination and improving economic opportunity, while people in the majority context may benefit more from opportunities for strengthening family and peer relationships.

POLICY POINTS: State‐level social and economic policies that expand tax credits, increase paid parental leave, raise the minimum wage, and increase tobacco taxes have been demonstrated to reduce adverse perinatal and infant health outcomes. These findings can help prioritize evidence‐based legislated policies to improve perinatal and infant outcomes in the United States. CONTEXT: Rates of preterm birth and infant mortality are alarmingly high in the United States. Legislated efforts may directly or indirectly reduce adverse perinatal and infant outcomes through the enactment of certain economic and social policies. METHODS: We conducted a narrative review to summarize the associations between perinatal and infant outcomes and four state‐level US policies. We then used a latent profile analysis to create a social and economic policy profile for each state based on the observed policy indicators. FINDINGS: Of 27 articles identified, nine focused on tax credits, eight on paid parental leave, four on minimum wages, and six on tobacco taxes. In all but three studies, these policies were associated with improved perinatal or infant outcomes. Thirty‐three states had tax credit laws, most commonly the earned income tax credit (n = 28, 56%). Eighteen states had parental leave laws. Two states had minimum wage laws lower than the federal minimum; 14 were equal to the federal minimum; 29 were above the federal minimum; and 5 did not have a state law. The average state tobacco tax was $1.76 (standard deviation = $1.08). The latent profile analysis revealed three policy profiles, with the most expansive policies in Western and Northeastern US states, and the least expansive policies in the US South. CONCLUSIONS: State‐level social and economic policies have the potential to reduce adverse perinatal and infant health outcomes in the United States. Those states with the least expansive policies should therefore consider enacting these evidence‐based policies, as they have shown a demonstratable benefit in other states.

POLICY POINTS: Policymakers considering introduction of a health insurance “public option” to lower health spending and reduce the number of uninsured can learn from Washington State, which offered the nation's first public option (“Cascade Care”) through its state exchange in 2021. This article examines insurer participation, pricing, and enrollment in the Washington public option. The public option was the lowest‐premium standard silver plan in 9 of the 19 counties in which it was offered. Cascade Care is available solely through private insurers. Voluntary participation of these insurers and uncertainty about the willingness of providers to participate may have hindered greater premium reductions and enrollment in the public option's first year. CONTEXT: State and federal policymakers considering introduction of a health insurance “public option” can learn from Washington State, which established the nation's first public option, with coverage beginning in January 2021. Public option plans were offered voluntarily by private insurers through the Washington Health Benefit Exchange and were subject to state‐mandated plan design and payment requirements. METHODS: We used plan data from the Washington Health Benefit Exchange, linked to data from the US Census Bureau, the American Hospital Association, and InterStudy. We compared geographic availability and premiums of, and enrollment in, public option and non–public option plans, as well as characteristics of counties where the public option was available and counties where the public option was the lowest‐premium plan. FINDINGS: At least one public option plan was available in 19 of 39 counties and was the lowest‐premium option in 9 of the 19 counties where it was available. Five insurers offered public option plans, including one new entrant to the state and one new entrant to the Exchange. While public option availability was more common in counties where the Exchange was bigger and more competitive, public option plans had the lowest premium in smaller, less competitive counties. In the first year, 1% of enrollees selected the public option, in part due to automatic reenrollment of the majority of returning enrollees in their 2020 plan. CONCLUSIONS: Public option plans offered a low‐premium choice in counties that otherwise had fewer affordable plans, but voluntary participation of insurers and providers and accompanying uncertainty about participation hindered widespread and substantial premium reductions. States should consider tying public option participation by insurers and providers to other state programs and using decision support tools to promote active enrollment. Federal policymakers can support state efforts while considering establishment of a national public option.

POLICY POINTS: Policies that increase county income levels, particularly for middle‐income households, may reduce low birth weight rates and shrink disparities between Black and White infants. Given the role of aggregate maternal characteristics in predicting low birth weight rates, policies that increase human capital investments (e.g., funding for higher education, job training) could lead to higher income levels while improving population birth outcomes. The association between county income levels and racial disparities in low birth weight is independent of disparities in maternal risks, and thus a broad set of policies aimed at increasing income levels (e.g., income supplements, labor protections) may be warranted. CONTEXT: Low birth weight (LBW

POLICY POINTS: Health actors can use the law more strategically in the pursuit of health and equity by addressing governance challenges (e.g., fragmented and overlapping mandates between health and nonhealth institutions), employing a broader rights‐based discourse in the public health policy process, and collaborating with the access to justice movement. Health justice partnerships provide a road map for implementing a sociolegal model of health to reduce health inequities by strengthening legal capacities for health among the health workforce and patients. This in turn will enable them to resolve health issues with legal solutions, to dismantle service silos, and to drive systemic policy and law reform. CONTEXT: In the field of public health, the law and legal systems remain a poorly understood and substantially underutilized tool to address unfair or unjust societal conditions underpinning health inequities. The aim of our article is to demonstrate the value of expanding from a social model of health to a sociolegal model of health and empowering health actors to use the law more strategically in the pursuit of health equity. METHODS: We propose a modified version of the framework for the social determinants of health (SDoH) equity developed by the 2008 World Health Organization Commission on the Social Determinants of Health by conceptually integrating the functions of the law as identified by the 2019 Lancet–O'Neill Institute Commission on Global Health and Law. FINDINGS: Access to justice provides a critical intersection between social models of public health and work in the justice fields. Addressing the inequities produced through the policies and institutions governing society unites the causes of those seeking to enhance access to justice and those seeking to reduce health inequities. Health justice partnerships (HJPs) are an example of a sociolegal model of health in action. Through the resolution of health issues with legal solutions at the individual level, the dismantling of service silos at the institutional level, and policy and law reform at the systemic level, HJPs demonstrate how the law can be used as a tool to reduce social and health inequities. CONCLUSIONS: Greater attention to law as a tool for health creates space for increased collaboration among legal and health scholars, practitioners, and advocates, particularly those working in the areas of the social determinants of health and access to justice, and a promising avenue for reducing health inequities.

Policy Points In the absence of federal action on rising prescription drug costs, we reviewed the details of five states that have enacted prescription drug-pricing boards seeking to lower drug prices based on products' value. Within these states, six such boards are currently authorized; they have similarities but vary in terms of structure, authority, scope, and leverage. As of June 2021, only one of the boards in our sample has conducted pricing reviews; legislators in other states can learn from the successes and challenges of existing boards. Prescription drug-pricing boards represent a novel and promising way to curb state spending and pay for value in prescription drugs but face legal and political barriers in implementation. Context Rising prescription drug costs are consuming a growing proportion of state and private budgets. In response, lawmakers have experimented with a variety of policies to contain spending and achieve value in prescription drugs. As part of this series of reforms, some state legislatures have recently authorized prescription drug-pricing boards to address the high prices of brand-name prescription drugs and assess the value of those drugs. Methods We identified state prescription drug-pricing boards in the United States, defined as any agency authorized by a state legislature to review specific drugs and pursue value-based drug prices. To describe the characteristics of the boards, we obtained public records of authorizing legislation, guidance documents, and board meeting minutes. We compared the boards' powers and responsibilities and analyzed completed pricing reviews. Findings Six state drug-pricing boards in five states met our definition; their design varied substantially. Two of the boards (New York Medicaid and Massachusetts) have authority over drug rebates paid by state Medicaid programs, one (New York Drug Accountability Board) has jurisdiction over state-regulated commercial insurance, and another three (Maine, Maryland, and New Hampshire) oversee non-Medicaid, state-funded insurance. Three boards are authorized to require manufacturers to confidentially submit information related to the pricing and clinical effectiveness of reviewed drugs to inform value determinations. Only one board (New York Medicaid) had completed pricing reviews as of June 3, 2021. Conclusions Boards' structure, scope, and statutory leverages to compel manufacturers to negotiate lower net costs are key factors that influence whether and to what extent boards can achieve cost savings for states. Though legal constraints may limit the effective reach of prescription drug-pricing boards, these agencies can enable states to address rising prescription drug costs, in part by virtue of their very existence. To overcome practical limitations, states seeking to implement similar policies can build on the experiences and designs of current boards.

Policy Points This article describes a strategic combination of research, advocacy, corporate campaigns, communications, grassroots mobilization, legislation, regulatory actions, and litigation against companies and government to secure a national policy to remove artificial trans fat from the US food system. Sharing lessons we learned can help inform policymakers, academics, policy practitioners, and students across disciplines. Some of our lessons are that system change means that all consumers benefit without the need for individual behavior change; research can both identify opportunities to improve health and support policy adoption; policy efforts can serve as public education campaigns; policy campaigns can drive marketplace changes; and engaging forward-thinking companies can diffuse opposition to passing a policy. Context For many decades, partially hydrogenated vegetable oil (PHO), the primary source of artificial trans fat in the American diet, was used widely in processed and restaurant foods. In the early 1990s, studies linked the consumption of artificial trans fat with heart disease. This article details how research and advocacy led to eliminating artificial trans fat from the US food supply. Methods We synthesized published studies of the health impact of trans fat, the legislative history of state and local trans fat bills, the Food and Drug Administration's (FDA) regulatory docket on trans fat labeling and its declaration that PHOs are no longer Generally Recognized as Safe (GRAS), and our own files, which included strategy documents, notes from meetings with the FDA staff, correspondence between advocates and the FDA, fact sheets, press releases, news clips, and other materials. Findings This history of trans fat provides insights into policy strategy and advocacy best practices that resulted in the removal of trans fat from food in the United States, preventing an estimated 50,000 premature deaths a year. The lessons we learned are that system change benefits all consumers without the need for individual behavior change; research can both identify opportunities to improve health through policy and support policy adoption; policy campaigns can serve as public education campaigns; policy can drive changes to products and the marketplace; and engaging forward-thinking companies can help diffuse opposition to passing a policy. Securing this policy required the persistence of scientists and health advocates in first discovering the risks and then using the science to secure policies to mitigate the identified harm. Conclusions An understanding of the tactics used to help attain the targeted policies and how challenges were addressed (such as through communications, leveraging an expanding research base and expert reports, showing that a national policy was feasible through voluntary corporate changes and state and local policy, and litigation against companies and government agencies) may provide a model for scientists, students, advocates, and policymakers. We hope this account will inform efforts to address other public health challenges, such as the current threats of excessive exposure to sodium and added sugars, which persist in the US food system.

POLICY POINTS: Purchasing health insurance is a complex task with multiple potential points of failure. In 2018, following the silver‐loading price shock, 20.2% of households earning above 200% of the federal poverty level with coverage through the two Covered California insurers who sold dominated silver plans purchased the inferior, dominated silver plan. Individuals who were automatically reenrolled were more likely to purchase an inferior, dominated plan. Automatic reenrollment rules and marketplace choice architecture should be modified to avoid placing people into dominated health insurance policies and help consumers more easily select superior coverage for themselves. CONTEXT: The Affordable Care Act (ACA) individual health insurance marketplaces rely on purchasers to make informed choices to impose price and quality discipline on a complex array of insurance products. A sudden and minimally expected policy shock in the fall of 2017—the termination of direct federal payment for cost‐sharing reduction (CSR) subsidies—led to a substantial change in the relative prices of silver and gold plans on the Covered California insurance marketplace. From 2014 to 2017, all gold plans in California were more expensive than comparable silver plans that were offered by the same insurer using the same network in the same county. For the 2018 plan year, however, some gold plans that had lower cost sharing also had lower premiums than did comparable silver plans, resulting in silver “dominated” plans being sold through Covered California. METHODS: We used the Covered California enrollment and product files from 2014 to 2018 in a retrospective data analysis of plan choice. We examined individuals earning above 200% of the federal poverty level who purchased plans from insurers who sold dominated silver plans in 2018. FINDINGS: We found that 3.9% of all Covered California enrollees in 2018 chose a strictly and transparently dominated plan. Among households with incomes above 200% of the federal poverty level that were enrolled in plans from the two insurers that offered dominated plans, 20.2% chose a dominated plan. Households that actively enrolled in 2018 and were enrolled in a silver plan in the previous year enrolled in a dominated plan at higher rates than did new enrollees and those who were enrolled in nonsilver plans in the previous year. More than 30% of households that had their coverage automatically renewed in 2018 enrolled in a dominated plan. On average, households enrolled in dominated plans in 2018 spent an additional $38.87 per month in premiums. CONCLUSIONS: Households routinely chose dominated plans and were exposed to both higher monthly premiums and higher potential cost sharing. Health insurance marketplaces should improve decision supports and choice curation to eliminate the possibility of individuals choosing dominated plans.

Policy Points Much concern about generic drug markets has emerged in recent policy debates. Important changes in regulations, the structure of purchasing, and the length of the drug supply chain have affected generic drug markets. Effective price competition remains the rule in generic markets for large-selling drugs. Smaller markets and those for injectable products often have less price competition and are more susceptible to supply disruptions. Context The image of generic drugs as a commodity sold in competitive markets is an oversimplification, as evidenced by increasing accounts of price spikes, sustained high price-cost margins, and market disruptions. The mismatch between the canonical economic model of generic drug markets and reality motivated our empirical project. Methods To explore recent changes in those factors impacting the supply and demand for generic drugs, we studied, from a variety of sources, the data on price, competition, supply disruptions and recalls, changes to the supply chain, and buy-side concentration. We examined quarterly data through 2018 for a cohort of 77 molecules that lost patent protection during the so-called patent cliff between 2010 and 2013. Findings On the supply side, we found that for large-market oral solids, generic entry and price declines were consistent with past studies showing a significant number of market entrants and substantial reductions in the average price of a molecule. In smaller markets for oral solids and injectable products, we observed fewer entrants, higher rates of exit, smaller price reductions, and, in some cases, considerable price instability. The number of reported shortages increased across all generic market types over time, with the rate of shortage increases especially pronounced in markets for injectable products. The number of product recalls also rose over our study period. Although we did not estimate causal effects, we did find several changes in the market environment for generic drugs that may contribute to these phenomena. The demand side for generics has become more concentrated. Supply chains rely more on producers outside the United States (particularly from China and India). Contracting practices have undergone changes that may inhibit competition in product supply. FDA regulatory scruitiny has increased. Conclusions Competition in generic drug markets varies widely by market size and product form. Recent changes in demand-side market structure imply more downward pressure on prices stemming from buy-side concentration. The FDA's greater regulatory oversight puts upward pressure on costs, and the lengthening of the supply chain increases production uncertainty for producers. Demand and supply-side changes point to further market instabilities across all generic markets due to producers' changing economic position.

Policy Points\ud Equitable access to a COVID‐19 vaccine in all countries remains a key policy objective, but experience of previous pandemics suggests access will be limited in developing countries, despite the rapid development of three successful vaccine candidates.\ud The COVAX Facility seeks to address this important issue, but the prevalence of vaccine nationalism threatens to limit the ability of the facility to meet both its funding targets and its ambitious goals for vaccine procurement.\ud A failure to adequately address the underlying lack of infrastructure in developing countries threatens to further limit the success of the COVAX Facility.\ud Context\ud Significant effort has been directed toward developing a COVID‐19 vaccine, which is viewed as the route out of the pandemic. Much of this effort has coalesced around COVAX, the multilateral initiative aimed at accelerating the development of COVID‐19 vaccines, and ensuring they are equitably available in low‐ and middle‐income countries (LMICs). This paper represents the first significant analysis of COVAX, and the extent to which it can be said to have successfully met these aims.\ud \ud Methods\ud This paper draws on the publicly available policy documents made available by the COVAX initiatives, as well as position papers and public statements from governments around the world with respect to COVID‐19 vaccines and equitable access. We analyze the academic literature regarding access to vaccines during the H1N1 pandemic. Finally, we consider the WHO Global Allocation System, and its principles, which are intended to guide COVAX vaccine deployment.\ud \ud Findings\ud We argue that the funding mechanism deployed by the COVAX Pillar appears to be effective at fostering at‐risk investments in research and development and the production of doses in advance of confirmation of clinical efficacy, but caution that this represents a win‐win situation for vaccine manufacturers, providing them with opportunity to benefit regardless of whether their vaccine candidate ever goes on to gain regulatory approval. We also argue that the success of the COVAX Facility with respect to equitable access to vaccine is likely to be limited, primarily as a result of the prevalence of vaccine nationalism, whereby countries adopt policies which heavily prioritize their own public health needs at the expense of others.\ud \ud Conclusions\ud Current efforts through COVAX have greatly accelerated the development of vaccines against COVID‐19, but these benefits are unlikely to flow to LMICs, largely due to the threat of vaccine nationalism.

POLICY POINTS: Spending on prescription drugs is much higher per capita in the United States than in most other industrialized nations, including France. Lower prescription drug spending in France is due to different approaches to managing drug prices, volume of prescribing, and global health budgets. Linking a drug's price to value both at the launch of the drug and over its lifetime is key to controlling spending. Regulations on prescription volume and global spending complement the interventions on prices. If the United States adopted the French approach to regulating drug pricing, Medicare could potentially save billions of dollars annually on prescription drug spending. CONTEXT: Prescription drug spending per capita in the United States is higher than in most other industrialized countries. Policymakers seeking to lower drug spending often suggest benchmarking prices against other countries, including France, which spends half as much as the United States per capita on prescription drugs. Because differences in drug prices may result from how markets are organized in each nation, we sought to directly compare drug prices and pricing regulations between the United States and France. METHODS: For the six brand‐name drugs with the highest gross expenditures in Medicare Part D in 2017, we compared the price dynamics in France and the United States between 2010 and 2018 and analyzed associations between price changes in each country and key regulatory events. We also comprehensively reviewed US and French laws and regulations related to drug pricing. FINDINGS: Prices for the six drugs studied were higher in the United States than in France. In 2018, if Medicare had paid French prices for the brand‐name drugs in our cohort, the agency would have saved $5.1 billion. We identified 12 factors that explain why the United States spends more than France on drugs, including variations in unit prices and the volume of prescriptions, driven by use of health technology assessment and value‐based pricing in France. CONCLUSIONS: Key drivers of lower drug spending in France compared to the United States are that the French government regulates drug prices when products are launched and prohibits substantial price increases after launch. The regulation of prescription drugs in France is governed by rules that can inform discussions of US prescription drug policy and potential Medicare price negotiations.

POLICY POINTS: Several intergovernmental organizations (Organisation for Economic Co‐operation and Development, World Health Organization, United Nations) are urging countries to use well‐being indicators (e.g., life satisfaction) in addition to traditional economic indicators when making important policy decisions. As the number of governments implementing this new approach grows, so does the need to continue evaluating the health and well‐being outcomes we might observe from policies aimed at improving life satisfaction. The results of this study suggest that life satisfaction is a valuable target for policies aiming to enhance several indicators of psychosocial well‐being, health behaviors, and physical health outcomes. CONTEXT: Several intergovernmental organizations (Organisation for Economic Co‐operation and Development, World Health Organization, United Nations) are urging countries to use well‐being indicators (e.g., life satisfaction) in addition to traditional economic indicators when making important policy decisions. As the number of governments implementing this new approach grows, so does the need to continue evaluating the health and well‐being outcomes we might observe from policies aimed at improving life satisfaction. METHODS: We evaluated whether positive change in life satisfaction (between t(0);2006/2008 and t(1);2010/2012) was associated with better outcomes on 35 indicators of physical, behavioral, and psychosocial health and well‐being (in t(2);2014/2016). Data were from 12,998 participants in the University of Michigan's Health and Retirement Study—a prospective and nationally representative cohort of US adults over age 50. FINDINGS: Participants with the highest (versus lowest) life satisfaction had better subsequent outcomes on some physical health indicators (lower risk of pain, physical functioning limitations, and mortality; lower number of chronic conditions; and higher self‐rated health) and health behaviors (lower risk of sleep problems and more frequent physical activity), and nearly all psychosocial indicators (higher positive affect, optimism, purpose in life, mastery, health mastery, financial mastery, and likelihood of living with spouse/partner; and lower depression, depressive symptoms, hopelessness, negative affect, perceived constraints, and loneliness) over the 4‐year follow‐up period. However, life satisfaction was not subsequently associated with many specific health conditions (i.e., diabetes, hypertension, stroke, cancer, heart disease, lung disease, arthritis, overweight/obesity, or cognitive impairment), other health behaviors (i.e., binge drinking or smoking), or frequency of contact with children, family, or friends. CONCLUSIONS: These results suggest that life satisfaction is a valuable target for policies aiming to enhance several indicators of psychosocial well‐being, health behaviors, and physical health outcomes.

POLICY POINTS: Despite 30 years of attention to eliminating population health inequity, it remains entrenched, calling for new approaches. Targeted universalism, wellness‐based local development, and Jedi Public Health approaches that are community informed, evidence based, and focused on improving everyday settings and diverse lived experiences are important policy directions. State and federal revenue transfers are necessary to mitigate the harms of austerity and assure greater equity in fiscal and population health in places like Detroit, Michigan. CONTEXT: US population health inequity remains entrenched, despite mandates to eliminate it. To promote a public health approach of consequence in this domain, stakeholders call for moving from risk‐factor epidemiology toward consideration of dynamic local variations in the physiological impacts of structured lived experience. METHODS: Using a community‐based, participatory research approach, we collected and analyzed a unique data set of 239 black, white, and Mexican adults from a stratified, multistage probability sample of three Detroit, Michigan, neighborhoods. We drew venous blood, collected saliva, took anthropometric measurements, and assayed specimens to measure allostatic load (AL), an indicator of stress‐mediated biological dysregulation, linking participants’ AL scores and survey responses. In a series of nested Poisson models, we regressed AL on socioeconomic, psychosocial, neighborhood, and behavioral stressors to test the hypothesis that race/ethnicity and poverty‐to‐income ratio (PIR) are conceptually fluctuating variables whose impacts on AL are sensitive to structured lived experience. FINDINGS: White and Mexican Detroit participants with PIR < 1 have higher AL than counterparts nationally; black participants in Detroit and nationwide had comparable AL. Within Detroit, disparities by PIR were higher in whites than blacks, with no significant difference by PIR in Mexicans. The size of estimated effects of having PIR < 1 for whites is 58 percentage points greater than that of Mexicans and twice that of blacks. CONCLUSIONS: Structurally rooted unobserved heterogeneity bias threatens the validity of independent main effects interpretations of associations between race/ethnicity, socioeconomic characteristics, or place and health. One‐size‐fits‐all analytic or policy models developed from the perspective of the dominant social group insufficiently address the experiences of diverse populations in specific settings and historical moments; nor do they recognize culturally mediated protective resources residents may have developed against material and psychosocial hardship.

Policy Points Millions of life-sustaining implantable devices collect and relay massive amounts of digital health data, increasingly by using user-downloaded smartphone applications to facilitate data relay to clinicians via manufacturer servers. Our analysis of health privacy laws indicates that most US patients may have little access to their own digital health data in the United States under the Health Insurance Portability and Accountability Act Privacy Rule, whereas the EU General Data Protection Regulation and the California Consumer Privacy Act grant greater access to device-collected data. Our normative analysis argues for consistently granting patients access to the raw data collected by their implantable devices. Context Millions of life-sustaining implantable devices collect and relay massive amounts of digital health data, increasingly by using user-downloaded smartphone applications to facilitate data relay to clinicians via manufacturer servers. Whether patients have either legal or normative claims to data collected by these devices, particularly in the raw, granular format beyond that summarized in their medical records, remains incompletely explored. Methods Using pacemakers and implantable cardioverter-defibrillators (ICDs) as a clinical model, we outline the clinical ecosystem of data collection, relay, retrieval, and documentation. We consider the legal implications of US and European privacy regulations for patient access to either summary or raw device data. Lastly, we evaluate ethical arguments for or against providing patients access to data beyond the summaries presented in medical records. Findings Our analysis of applicable health privacy laws indicates that US patients may have little access to their raw data collected and held by device manufacturers in the United States under the Health Insurance Portability and Accountability Act Privacy Rule, whereas the EU General Data Protection Regulation (GDPR) grants greater access to device-collected data when the processing of personal data falls under the GDPR's territorial scope. The California Consumer Privacy Act, the "little sister" of the GDPR, also grants greater rights to California residents. By contrast, our normative analysis argues for consistently granting patients access to the raw data collected by their implantable devices. Smartphone applications are increasingly involved in the collection, relay, retrieval, and documentation of these data. Therefore, we argue that smartphone user agreements are an emerging but potentially underutilized opportunity for clarifying both legal and ethical claims for device-derived data. Conclusions Current health privacy legislation incompletely supports patients' normative claims for access to digital health data.

Policy Points US policymakers considering proposals to expand public health care (such as "Medicare for all") as a means of reducing inequalities in health care access and use could learn from the experiences of nations where well-funded universal health care systems are already in place. In England, which has a publicly funded universal health care system, the use of core inpatient services by adults 65 years and older is equal across groups defined by education level, after controlling for health status. However, variation among these groups in the use of outpatient and emergency department care developed between 2010 and 2015, a period of relative financial austerity. Based on England's experience, introducing universal health care in the United States seems likely to reduce, but not entirely eliminate, inequalities in health care use across different population groups. Context Expanding access to health care is once again high on the US political agenda, as is concern about those who are being "left behind." But is universal health care that is largely free at the point of use sufficient to eliminate inequalities in health care use? To explore this question, we studied variation in the use of hospital care among education-level-defined groups of older adults in England, before and after controlling for differences in health status. In England, the National Health Service (NHS) provides health care free to all, but the growth rate for NHS funding has slowed markedly since 2010 during a widespread austerity program, potentially increasing inequalities in access and use. Methods Novel linkage of data from six waves (2004-2015) of the English Longitudinal Study of Ageing (ELSA) with participants' hospital records (Hospital Episode Statistics [HES]) produced longitudinal data for 7,713 older adults (65 years and older) and 25,864 observations. We divided the sample into three groups by education level: low (no formal qualifications), mid (completed compulsory education), and high (at least some higher education). Four outcomes were examined: annual outpatient appointments, elective inpatient admissions, emergency inpatient admissions, and emergency department (ED) visits. We estimated regressions for the periods 2004-2005 to 2008-2009 and 2010-2011 to 2014-2015 to examine whether potential education-related inequalities in hospital use increased after the growth rate for NHS funding slowed in 2010. Findings For the study period, our sample of ELSA respondents in the low-education group made 2.44 annual outpatient visits. In comparison, after controlling for health status, we found that participants in the high-education group made an additional 0.29 outpatient visits annually (95% confidence interval [CI], 0.11-0.47). Additional outpatient health care use in the high-education group was driven by follow-up and routine appointments. This inequality widened after 2010. Between 2010 and 2015, individuals in the high-education group made 0.48 (95% CI, 0.21-0.74) more annual outpatient visits than those in the low-education (16.9% [7.5% to 26.2%] of annual average 2.82 visits). In contrast, after 2010, the high-education group made 0.04 (95% CI, -0.075 to 0.001) fewer annual ED visits than the low-education group, which had a mean of 0.30 annual ED visits. No significant differences by education level were found for elective or emergency inpatient admissions in either period. Conclusions After controlling for demographics and health status, there was no evidence of inequality in elective and emergency inpatient admissions among the education groups in our sample. However, a period of financial budget tightening for the NHS after 2010 was associated with the emergence of education gradients in other forms of hospital care, with respondents in the high-education group using more outpatient care and less ED care than peers in the low-education group. These estimates point to rising inequalities in the use of hospital care that, if not reversed, could exacerbate existing health inequalities in England. Although the US and UK settings differ in many ways, our results also suggest that a universal health care system would likely reduce inequality in US health care use.

Policy Points Protective transgender-specific policies (including those related to experiences of discrimination, health insurance coverage, and changing legal documents) are associated with increased access to medical gender affirmation services (hormone treatment, therapy/counseling) for transgender and other gender-diverse people. Restrictive transgender-specific policies are associated with less access to these services. The relationship between race/ethnicity and use of medical gender affirmation services varies across states and is context specific, indicating that race/ethnicity also plays a role in access to these types of care across states. Advocacy is needed to prevent or overturn restrictive policies and promote protective policies for transgender and other gender-diverse people, especially for people of color. Context In the 2010s, the number of federal, state, and local transgender-specific policies increased. Some of these policies advanced protections for transgender and other gender-diverse (TGGD) people, and others were restrictive. Little is known about the relationships between these policies and use of medical gender affirmation services (eg, hormone treatment, therapy/counseling), or about how these associations may vary among different racial and ethnic groups. Methods Multilevel modeling was used to examine the associations between state-level transgender-specific policies and the use of medical gender affirmation services among TGGD people in the United States. Data are from the 2015 U.S. Trans Survey of nearly 28,000 TGGD people. The medical gender affirmation services examined in this study were hormone treatment and therapy/counseling. The state policies we analyzed addressed discrimination, health insurance coverage, and changing legal documents; these policies were measured individually and as a composite index. Race/ethnicity was included in the multilevel regression models as a random slope to determine whether the relationship between race/ethnicity and the use of medical gender affirmation services varied by state. Findings Individual policies and the policy index were associated with both outcomes (use of therapy/counseling and hormone treatment services), indicating that protective policies were associated with increased care. Broad religious exemption laws and Medicaid policies that excluded transgender-specific care were both associated with less use of therapy/counseling, whereas transgender-care-inclusive Medicaid policies were associated with more use of therapy/counseling. Nondiscrimination protections that include gender identity were associated with increased use of hormone treatment services. The relationship between race/ethnicity and medical gender affirmation services varied across states. Conclusions State-level transgender-specific policies influence medical gender affirmation service use and seem to affect use by non-Hispanic white TGGD people and TGGD people of color differently. Advocacy is needed to repeal restrictive policies and promote protective policies in order to reduce health inequities among TGGD people, especially people of color.

Policy Points This article reconceptualizes our understanding of the opioid epidemic and proposes six strategies that address the epidemic's social roots. In order to successfully reduce drug-related mortality over the long term, policymakers and public health leaders should develop partnerships with people who use drugs, incorporate harm reduction interventions, and reverse decades of drug criminalization policies. Context Drug overdose is the leading cause of injury-related death in the United States. Synthetic opioids, predominantly illicit fentanyl and its analogs, surpassed prescription opioids and heroin in associated mortality rates in 2016. Unfortunately, interventions fail to fully address the current wave of the opioid epidemic and often omit the voices of people with lived experiences regarding drug use. Every overdose death is a culmination of a long series of policy failures and lost opportunities for harm reduction. Methods In this article, we conducted a scoping review of the opioid literature to propose a novel framework designed to foreground social determinants more directly into our understanding of this national emergency. The "continuum of overdose risk" framework is our synthesis of the global evidence base and is grounded in contemporary theories, models, and policies that have been successfully applied both domestically and internationally. Findings De-escalating overdose risk in the long term will require scaling up innovative and comprehensive solutions that have been designed through partnerships with people who use drugs and are rooted in harm reduction. Conclusions Without recognizing the full drug-use continuum and the role of social determinants, the current responses to drug overdose will continue to aggravate the problem they are trying to solve.

Policy Points Changes in US state policies since the 1970s, particularly after 2010, have played an important role in the stagnation and recent decline in US life expectancy. Some US state policies appear to be key levers for improving life expectancy, such as policies on tobacco, labor, immigration, civil rights, and the environment. US life expectancy is estimated to be 2.8 years longer among women and 2.1 years longer among men if all US states enjoyed the health advantages of states with more liberal policies, which would put US life expectancy on par with other high-income countries. Context Life expectancy in the United States has increased little in previous decades, declined in recent years, and become more unequal across US states. Those trends were accompanied by substantial changes in the US policy environment, particularly at the state level. State policies affect nearly every aspect of people's lives, including economic well-being, social relationships, education, housing, lifestyles, and access to medical care. This study examines the extent to which the state policy environment may have contributed to the troubling trends in US life expectancy. Methods We merged annual data on life expectancy for US states from 1970 to 2014 with annual data on 18 state-level policy domains such as tobacco, environment, tax, and labor. Using the 45 years of data and controlling for differences in the characteristics of states and their populations, we modeled the association between state policies and life expectancy, and assessed how changes in those policies may have contributed to trends in US life expectancy from 1970 through 2014. Findings Results show that changes in life expectancy during 1970-2014 were associated with changes in state policies on a conservative-liberal continuum, where more liberal policies expand economic regulations and protect marginalized groups. States that implemented more conservative policies were more likely to experience a reduction in life expectancy. We estimated that the shallow upward trend in US life expectancy from 2010 to 2014 would have been 25% steeper for women and 13% steeper for men had state policies not changed as they did. We also estimated that US life expectancy would be 2.8 years longer among women and 2.1 years longer among men if all states enjoyed the health advantages of states with more liberal policies. Conclusions Understanding and reversing the troubling trends and growing inequalities in US life expectancy requires attention to US state policy contexts, their dynamic changes in recent decades, and the forces behind those changes. Changes in US political and policy contexts since the 1970s may undergird the deterioration of Americans' health and longevity.

POLICY POINTS: Suboptimal intake of fruit and vegetables is associated with increased risk of diet‐related diseases. A national retail‐based fruit and vegetable subsidy program could broadly benefit the health of the entire population. Existing fruit and vegetable subsidy programs can inform potential implementation mechanisms; Congress's powers to tax, spend, and regulate interstate commerce can be leveraged to create a federal program. Legal and administrative feasibility considerations support a conditional funding program or a federal‐state cooperative program combining regulation, licensing, and state or local options for flexible implementation strategies. Strategies to engage key stakeholders would enable the program to utilize lessons learned from existing programs. CONTEXT: Suboptimal intake of fruit and vegetables (F&Vs) is associated with increased risk of diet‐related diseases. Yet, there are no US government programs to support increased F&V consumption nationally for the whole population, most of whom purchase food at retail establishments. To inform policy discussion and implementation, we identified mechanisms to effectuate a national retail‐based F&V subsidy program. METHODS: We conducted legal and policy research using LexisNexis, the UConn Rudd Center Legislation Database, the Centers for Disease Control and Prevention Chronic Disease State Policy Tracking System, the US Department of Agriculture's website, Congress.gov, gray literature, and government reports. First, we identified existing federal, state, local, and nongovernmental organization (NGO) policies and programs that subsidize F&Vs. Second, we evaluated Congress's power to implement a national retail‐based F&V subsidy program. FINDINGS: We found five federal programs, three federal bills, four state laws, and 17 state (including the District of Columbia [DC]) bills to appropriate money to supplement federal food assistance programs with F&Vs; 74 programs (six multistate, 22 state [including DC], and 46 local) administered by state and local governments and NGOs that incentivize the purchase of F&Vs for various subpopulations; and two state laws and 11 state bills to provide tax exemptions for F&Vs. To create a national F&V subsidy program, Congress could use its Commerce Clause powers or its powers to tax or spend, through direct regulation, licensing, taxation, tax incentives, and conditional funding. Legal and administrative feasibility considerations support a voluntary conditional funding program or, as a second option, a mandatory federal‐state cooperative program combining regulation and licensing. CONCLUSIONS: Multiple existing programs provide an important foundation to inform potential implementation mechanisms for a national F&V subsidy program. Results also highlight the value of state and local participation to leverage existing networks and stakeholder knowledge.

Policy Points Community-engaged research (CEnR) engenders meaningful academic-community partnerships to improve research quality and health outcomes. CEnR has increasingly been adopted by health care systems, funders, and communities looking for solutions to intractable problems. It has been difficult to systematically measure CEnR's impact, as most evaluations focus on project-specific outcomes. Similarly, partners have struggled with identifying appropriate measures to assess outcomes of interest. To make a case for CEnR's value, we must demonstrate the impacts of CEnR over time. We compiled recent measures and developed an interactive data visualization to facilitate more consistent measurement of CEnR's theoretical domains. Context Community-engaged research (CEnR) aims to engender meaningful academic-community partnerships to increase research quality and impact, improve individual and community health, and build capacity for uptake of evidence-based practices. Given the urgency to solve society's pressing public health problems and increasing competition for funding, it is important to demonstrate CEnR's value. Most evaluations focus on project-specific outcomes, making it difficult to demonstrate CEnR's broader impact. Moreover, it is challenging for partnerships to identify assessments of interest beyond process measures. We conducted a mapping review to help partnerships find and select measures to evaluate CEnR projects and to characterize areas where further development of measures is needed. Methods We searched electronic bibliographic databases using relevant search terms from 2009 to 2018 and scanned CEnR projects to identify unpublished measures. Through review and reduction, we found 69 measures of CEnR's context, process, or outcomes that are potentially generalizable beyond a specific health condition or population. We abstracted data from descriptions of each measure to catalog purpose, aim (context, process, or outcome), and specific domains being measured. Findings We identified 28 measures of the conditions under which CEnR is conducted and factors to support effective academic-community collaboration (context); 43 measures evaluating constructs such as group dynamics and trust (process); and 43 measures of impacts such as benefits and challenges of CEnR participation and system and capacity changes (outcomes). Conclusions We found substantial variation in how academic-community partnerships conceptualize and define even similar domains. Achieving more consistency in how partnerships evaluate key constructs could reduce measurement confusion apparent in the literature. A hybrid approach whereby partnerships discuss common metrics and develop locally important measures can address CEnR's multiple goals. Our accessible data visualization serves as a convenient resource to support partnerships' evaluation goals and may help to build the evidence base for CEnR through the use of common measures across studies.

Policy Points: - Integrated care is best understood as an emergent set of practices intrinsically shaped by contextual factors, and not as a single intervention to achieve predetermined outcomes. - Policies to integrate care that facilitate person‐centered, relationship‐based care can potentially contribute to (but not determine) improved patient experiences. - There can be an association between improved patient experiences and system benefits, but these outcomes of integrated care are of different orders and do not necessarily align. - Policymakers should critically evaluate integrated care programs to identify and manage conflicts and tensions between a program's aims and the context in which it is being introduced. Context: Integrated care is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. Despite examples of successful integrated care systems, evidence for consistent and reproducible benefits remains elusive. We sought to inform policy and practice by conducting a systematic hermeneutic review of literature covering integrated care strategies and concepts. Methods: We used an emergent search strategy to identify 71 sources that considered what integrated care means and/or tested models of integrated care. Our analysis entailed (1) comparison of strategies and concepts of integrated care, (2) tracing common story lines across multiple sources, (3) developing a taxonomy of literature, and (4) generating a novel interpretation of the heterogeneous strategies and concepts of integrated care. Findings: We identified four perspectives on integrated care: patients’ perspectives, organizational strategies and policies, conceptual models, and theoretical and critical analysis. We subdivided the strategies into four framings of how integrated care manifests and is understood to effect change. Common across empirical and conceptual work was a concern with unity in the face of fragmentation as well as the development and application of similar methods to achieve this unity. However, integrated care programs did not necessarily lead to the changes intended in experiences and outcomes. We attribute this gap between expectations and results, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other. Conclusions: Those looking for universal answers to narrow questions about whether integrated care “works” are likely to remain disappointed. Models of integrated care need to be valued for their heuristic rather than predictive powers, and integration understood as emerging from particular as well as common contexts.

Policy Points: - For complex reasons, the promise of “precision medicine” based on molecular pathways remains unrealized for many conditions. - Clinical practice guidelines (theoretically, at least) can act as “trailblazers” to introduce tests and treatments that reflect precision medicine discoveries. - We describe a detailed case study from the United Kingdom in which such an attempt was (so far) unsuccessful and show how this case provides generalizable lessons. - Policymakers should be wary of using clinical practice guidelines as the sole, or even the primary, lever for introducing precision medicine. Context: Precision medicine, which addresses underlying molecular mechanisms of disease, depends on new technologies that measure specific biomarkers, leading (it is anticipated) to more accurate diagnosis, patient stratification, and tailored treatment. These technologies can be disruptive—that is, they make possible, and often require, radical changes to clinical practice and service organization—thereby improving quality, safety, or efficiency of care. Clinical practice guidelines may act as “trailblazers,” introducing and legitimizing novel technologies and practices. Methods: We describe a case study of an attempt by academic researchers to radically change asthma management in the United Kingdom using a precision medicine biomarker (fractional exhaled nitric oxide, FeNO), measured using a portable breath device. We collected a wide‐ranging data set that included more than 100 documents, 61 interviews, and 150 hours of ethnographic observation, and we analyzed it using technology‐enhanced strong structuration theory (TESST). Findings: Our study describes a so‐far unsuccessful attempt by academic respiratory medicine researchers to pave the way for a precision medicine approach to asthma using a government‐endorsed national guideline. These researchers considered asthma management, especially in primary care, to be characterized by overdiagnosis and poor tailoring of treatment; engaged a national guideline development body in an effort to fix this problem; and ensured that the guideline required primary care clinicians to use FeNO technology for diagnosis and monitoring. However, clinicians working outside the tertiary referral centers did not accept, or agree to enact, the vision of precision medicine inscribed in the guideline—for multiple professional, operational, and economic reasons. Conclusions: “Trailblazer” guidelines, in which new technologies are recommended, may succeed as catalysts of change only in a limited way for interested individuals and groups. In the absence of a wider program of professionally led and adequately resourced change efforts, such guidelines will lack meaning, legitimacy, and authority among intended users and may be strongly resisted.

Policy Points Social policies might not only improve economic well-being, but also health. Health policy experts have therefore advocated for investments in social policies both to improve population health and potentially reduce health system costs. Since the 1960s, a large number of social policies have been experimentally evaluated in the United States. Some of these experiments include health outcomes, providing a unique opportunity to inform evidence-based policymaking. Our comprehensive review and meta-analysis of these experiments find suggestive evidence of health benefits associated with investments in early life, income support, and health insurance interventions. However, most studies were underpowered to detect health outcomes. CONTEXT: Insurers and health care providers are investing heavily in nonmedical social interventions in an effort to improve health and potentially reduce health care costs. METHODS: We performed a systematic review and meta-analysis of all known randomized social experiments in the United States that included health outcomes. We reviewed 5,880 papers, reports, and data sources, ultimately including 61 publications from 38 randomized social experiments. After synthesizing the main findings narratively, we conducted risk of bias analyses, power analyses, and random-effects meta-analyses where possible. Finally, we used multivariate regressions to determine which study characteristics were associated with statistically significant improvements in health outcomes. FINDINGS: The risk of bias was low in 17 studies, moderate in 11, and high in 33. Of the 451 parameter estimates reported, 77% were underpowered to detect health outcomes. Among adequately powered parameters, 49% demonstrated a significant health improvement, 44% had no effect on health, and 7% were associated with significant worsening of health. In meta-analyses, early life and education interventions were associated with a reduction in smoking (odds ratio [OR] = 0.92, 95% confidence interval [CI] 0.86-0.99). Income maintenance and health insurance interventions were associated with significant improvements in self-rated health (OR = 1.20, 95% CI 1.06-1.36, and OR = 1.38, 95% CI 1.10-1.73, respectively), whereas some welfare-to-work interventions had a negative impact on self-rated health (OR = 0.77, 95% CI 0.66-0.90). Housing and neighborhood trials had no effect on the outcomes included in the meta-analyses. A positive effect of the trial on its primary socioeconomic outcome was associated with higher odds of reporting health improvements. We found evidence of publication bias for studies with null findings. CONCLUSIONS: Early life, income, and health insurance interventions have the potential to improve health. However, many of the included studies were underpowered to detect health effects and were at high or moderate risk of bias. Future social policy experiments should be better designed to measure the association between interventions and health outcomes.

Policy Points Because bundled payments are relatively new and require a different type of collaboration among payers, providers, and other actors, their design and implementation process is complex. By sorting the 53 key elements that contribute to this complexity into specific pre- and postcontractual phases as well as the actors involved in the health system, this framework provides a comprehensive overview of this complexity from a payer's perspective. Strategically, the design and implementation of bundled payments should not be approached by payers as merely the introduction of a new contracting model, but as part of a broader transformation into a more sustainable, value-based health care system. Context: Traditional fee-for-service (FFS) payment models in health care stimulate volume-driven care rather than value-driven care. To address this issue, increasing numbers of payers are adopting contracts based on bundled payments. Because their design and implementation are complex, understanding the elements that contribute to this complexity from a payer's perspective might facilitate their adoption. Consequently, the objective of our study was to identify and structure the key elements in the design and implementation of bundled payment contracts. Methods: Two of us independently and systematically examined the literature to identify all the elements considered relevant to our objective. We then developed a framework in which these elements were arranged according to the specific phases of a care procurement process and actors’ interactions at various levels of the health system. Findings: The final study sample consisted of 147 articles in which we identified the 53 elements included in the framework. These elements were found in all phases of the pre- and postcontractual procurement process and involved actors at different levels of the health care system. Examples of elements that were cited frequently and are typical of bundled payment procurement, as opposed to FFS procurement, are (1) specification of care services, patients’ characteristics, and corresponding costs, (2) small and heterogeneous patient populations, (3) allocation of payment and savings/losses among providers, (4) identification of patients in the bundle, (5) alignment of the existing care delivery model with the new payment model, and (6) limited effects on quality and costs in the first pilots and demonstrations. Conclusions: Compared with traditional FFS payment models, bundled payment contracts tend to introduce an alternative set of (financial) incentives, touch on almost all aspects of governance within organizations, and demand a different type of collaboration among organizations. Accordingly, payers should not strategically approach their design and implementation as merely the adoption of a new contracting model, but rather as part of a broader transformation toward a more sustainable value-based health care system, based less on short-term transactional negotiations and more on long-term collaborative relationships between payers and providers.

Policy Points Interventions in a regional system with intertwined threats and costs should address those threats that have the strongest, quickest, and most pervasive cross-impacts. Instead of focusing on an individual county's apparent shortcomings, a regional intervention portfolio can yield greater results when it is designed to counter those systemic threats, especially poverty and inadequate social support, that most undermine health and well-being virtually everywhere. Likewise, efforts to reduce smoking, addiction, and violent crime and to improve routine care, health insurance, and youth education are important for most counties to unlock both short- and long-term potential. CONTEXT Counties across the United States must contend with multiple, intertwined threats and costs that defy simple solutions. Decision makers face the necessary but difficult task of prioritizing those interventions with the greatest potential to produce equitable health and well-being. METHODS Using County Health Rankings data for a predefined peer group of 39 urban US counties, we performed statistical regressions to identify 37 cross-impacts among 15 threats to health and well-being. Adding appropriate time delays, we then developed a dynamic model of these cross-impacts and simulated each of the counties over 20 years to assess the likely impact of 12 potential interventions-individually and in a combined portfolio-for three outcomes: (1) years of potential life lost, (2) fraction of adults in fair or poor health, and (3) total spending on urgent services. FINDINGS The combined portfolio yielded improvements by year 20 that are considerably greater than those at year 5, indicating that the time delays have a major effect. Despite the wide variation in threat levels across counties, the list of top-ranked interventions is strikingly similar. Poverty reduction and social support were the most highly ranked interventions, even in the shorter term, for all outcomes in all counties. Interventions affecting smoking, addiction, routine care, health insurance, violent crime, and youth education also were important contributors to some outcomes. CONCLUSIONS To safeguard health and well-being in a system dominated by tangled threats and costs, the most important priorities for a county cannot be simply inferred from a profile of its relative strengths and weaknesses. Two interventions stood out as the top priorities for almost all the counties in this study, and six others also were important contributors. Interventions directed toward these priority areas are likely to yield the greatest impact, irrespective of the county's specifics. A significant concentration of resources in a regional portfolio therefore ought to go to these strongest contributors for equitable health and well-being.

Policy Points Although preventable chronic conditions such as type 2 diabetes carry a significant cost and health burden, few lifestyle interventions have been scaled at a national policy level. The translation of the National Diabetes Prevention Program lifestyle intervention from research to a Medicare-covered service can serve as a model for national adoption of other interventions that have the potential to improve population health. The successful translation of the National Diabetes Prevention Program has depended on the collaboration of government agencies, academic researchers, community-based healthcare providers, payers, and other parties. Context Many evidence-based health interventions never achieve national implementation. This article analyzes factors that supported the translation and national implementation of a lifestyle change intervention to prevent or delay type 2 diabetes in individuals with prediabetes. Methods We used the Knowledge to Action framework, which was developed to map how science is translated into effective health programs, to examine how the evidence-based intervention from the 2002 Diabetes Prevention Program trial was translated into the Centers for Disease Control and Prevention's large-scale National Diabetes Prevention Program, eventually resulting in payment for the lifestyle intervention as a Medicare-covered service. Findings Key findings of our analysis include the importance of a collaboration among researchers, policymakers, and payers to encourage early adopters; development of evidence-based, national standards to support widespread adoption of the intervention; and use of public input from community organizations to scale the intervention to a national level. Conclusions This analysis offers timely lessons for other high-value, scalable interventions attempting to move beyond the evidence-gathering phase and into translation and institutionalization.

Policy Points Preemption is a legal doctrine whereby a higher level of government may limit or even eliminate the power of a lower level of government to regulate a certain issue. Some state legislatures are using preemption with increasing regularity to thwart local policies that have the potential to reduce health inequities. Despite recent trends, preemption is not inherently adversarial to public health, equity, or good governance but rather reflects its wielder's goals and values. Existing frameworks for assessing preemption fail to reconcile its potential to both advance and hinder health equity. An equity-first preemption framework can facilitate case-by-case assessments of whether preemption is likely to worsen inequities or whether it is an appropriate response to address existing inequities. Robust empirical evidence is needed to develop and operationalize such a framework. Context Due to the inequitable distribution of various social determinants of health, disparities in health and well-being are tied to where an individual lives. In the United States, a zip code often better predicts a person's health than their genetic code. As communities seek to redress these inequities, many find that, due to state preemption, their zip code also dictates their ability to pursue more equitable laws through local government action. Preemption is a legal doctrine whereby a higher level of government may limit or even eliminate the power of a lower level of government to regulate a certain issue. Methods We conducted a literature review to survey existing scholarship about the effects of preemption on public health and health equity using online databases such as PubMed, WestLaw, and Google Scholar. We also cohosted a series of cross-sector, interdisciplinary research convenings with preemption, public health, and equity experts. Based on our findings, this article reviews the role of law and policy in the genesis of health inequities and highlights how preemption has both created and alleviated such inequities. We demonstrate how a normative framework rooted in redressing health inequities can advance a more just approach to preemption and outline a research agenda to support future action. Findings Law and policy have been central to creating health inequities, and while those same tools can promote health equity, some state legislatures are using preemption with increasing regularity to thwart local policies that may improve health and equity. Nevertheless, preemption is not inherently adversarial to public health, equity, or good governance. Preemptive federal civil rights laws, for example, have countered government-sanctioned discrimination. However, existing frameworks for assessing preemption fail to reconcile its potential to both advance and hinder health equity. Conclusions Shortcomings in existing preemption frameworks demonstrate the need for new approaches to elevate equity as a central consideration in assessing preemption. We propose the development of an equity-first preemption framework to establish evidence-based criteria for assessing when preemption will enhance or inhibit equity and a research agenda for developing the evidence necessary to inform and operationalize the framework. An equity-first reconceptualization of preemption can help ensure that local governments remain places of innovation while allowing states and the federal government to block local actions that are likely to create or perpetuate inequities.

Policy Points US maternal mortality rates (MMRs) display considerable racial disparities and exceed those of other developed countries. While worldwide MMRs have dropped sharply since the 1990s, the US MMR appears to be rising. We provide strong evidence of the effectiveness of pregnancy-related public health spending on improvements in maternal health. Using longitudinal data from Florida counties, we found that spending on public health significantly reduced the MMR among black mothers and narrowed black-white outcome disparities. Each 10% increase in pregnancy-related public health expenditures was associated with a 13.5% decline in MMR among blacks and a 20.0% reduction in black-white disparities. Context Maternal mortality rates in the United States exceed those of other developed countries. Moreover, these rates show considerable racial disparities, in which black mothers are at three to four times the risk compared with their white counterparts. With more than half of all maternal deaths deemed to be preventable, public health interventions have the potential to improve maternal health along with other pregnancy outcomes. This rigorous longitudinal study examines the impact of a package of pregnancy-related public health programs on maternal mortality rates. Methods We analyzed administrative data on pregnancy-related public health expenditures, maternal mortality rates, and sociodemographic factors from all 67 Florida counties between 2001 and 2014. Florida provides consistent counts of maternal deaths for the entire period of this analysis. We estimated both fixed-effects ordinary least squares regressions (OLS) and generalized method of moments (GMM) models. GMM enabled us to identify the impact of public health expenditures on maternal mortality rates while also addressing both potential endogeneity and serial correlation problems. We also provide a series of robustness and falsification tests. Findings Overall, a 10% increase in targeted public health expenditures led to a weakly significant decline in overall maternal mortality rates of 3.9%. The estimated effect for white mothers was not statistically significant. However, we found statistically significant improvements for black mothers. Specifically, a 10% increase in pregnancy-related public health spending led to a 13.5% decline in maternal mortality rates among black mothers and a 20.0% reduction in the black-white maternal mortality gap. Conclusions Our analysis provides strong evidence of the effectiveness of public health programs in reducing maternal mortality rates and addressing racial disparities.

Policy Points This scoping review reveals a growing literature on the effects of certain state opioid misuse prevention policies, but persistent gaps in evidence on other prevalent state policies remain. Policymakers interested in reducing the volume and dosage of opioids prescribed and dispensed can consider adopting robust prescription drug monitoring programs with mandatory access provisions and drug supply management policies, such as prior authorization policies for high-risk prescription opioids. Further research should concentrate on potential unintended consequences of opioid misuse prevention policies, differential policy effects across populations, interventions that have not received sufficient evaluation (eg, Good Samaritan laws, naloxone access laws), and patient-related outcomes. Context In the midst of an opioid crisis in the United States, an influx of state opioid misuse prevention policies has provided new opportunities to generate evidence of policy effectiveness that can inform policy decisions. We conducted a scoping review to synthesize the available evidence on the effectiveness of US state interventions to improve patient and provider outcomes related to opioid misuse and addiction. Methods We searched six online databases to identify evaluations of state opioid policies. Eligible studies examined legislative and administrative policy interventions that evaluated (a) prescribing and dispensing, (b) patient behavior, or (c) patient health. Findings Seventy-one articles met our inclusion criteria, including 41 studies published between 2016 and 2018. These articles evaluated nine types of state policies targeting opioid misuse. While prescription drug monitoring programs (PDMPs) have received considerable attention in the literature, far fewer studies addressed other types of state policy. Overall, evidence quality is very low for the majority of policies due to a small number of evaluations. Of interventions that have been the subject of considerable research, promising means of reducing the volume and dosages of opioids prescribed and dispensed include drug supply management policies and robust PDMPs. Due to low study number and quality, evidence is insufficient to draw conclusions regarding interventions targeting patient behavior and health outcomes, including naloxone access laws and Good Samaritan laws. Conclusions Recent research has improved the evidence base on several state interventions targeting opioid misuse. Specifically, moderate evidence suggests that drug supply management policies and robust PDMPs reduce opioid prescribing. Despite the increase in rigorous evaluations, evidence remains limited for the majority of policies, particularly those targeting patient health-related outcomes.

POLICY POINTS: When communicating with state legislators, advocates for state behavioral health parity laws should emphasize that the laws do not increase insurance premiums. Legislators’ opinions about the impacts of state behavioral health parity laws and the effectiveness of behavioral health treatment have more influence on support for the laws than do their political party affiliation or state‐level contextual factors. Reducing legislators’ stigma toward people with mental illness could increase their support for state behavioral health parity laws. CONTEXT: Comprehensive state behavioral health parity legislation (C‐SBHPL) is an evidence‐based policy that improves access and adherence to behavioral health treatments. However, adoption of C‐SBHPL by state legislators is low. Little is known about how C‐SBHPL evidence might be most effectively disseminated to legislators or how legislators’ fixed characteristics (eg, ideology), mutable characteristics (eg, beliefs about the policy's impact), and state‐level contextual factors might influence their support for behavioral health policies. The purpose of our study is (1) to describe the associations between legislators’ fixed and mutable characteristics, state‐level contextual factors, and support for C‐SBHPL; and (2) to identify the mutable characteristics of legislators independently associated with C‐SBHPL support. METHODS: We conducted a multimodal (post mail, email, telephone) survey of US state legislators in 2017 (N = 475). The dependent variable was strong support for C‐SBHPL, and the independent variables included legislators’ fixed and mutable characteristics and state‐level contextual factors. We conducted multivariable, multilevel (legislator, state) logistic regression. FINDINGS: Thirty‐nine percent of the legislators strongly supported C‐SBHPL. After adjustment, the strongest predictors of C‐SBHPL support were beliefs that C‐SBHPL increases access to behavioral health treatments (aOR = 5.85; 95% CI = 2.41, 14.20) and does not increase insurance premiums (aOR = 2.70; 95% CI = 1.24, 5.90). Stigma toward people with mental illness was inversely associated with support (aOR = 0.86; 95% CI = 0.78, 0.95). After adjustment, ideology was the only fixed characteristic significantly associated with support for C‐SBHPL. State‐level contextual factors did not moderate associations between mutable characteristics and support for C‐SBHPL. CONCLUSIONS: Legislators’ mutable characteristics are stronger predictors of C‐SBHPL support than are most of their fixed characteristics and all state‐level contextual factors, and thus should be targeted by dissemination efforts.

Policy Points Widespread diffusion of policy innovation is the exception rather than the rule, depending as it does on the convergence of a variety of intellectual, political, economic, and organizational forces. The history of Assertive Community Treatment (ACT) provides a compelling case study of this process while also showing how conditions may shift over time, altering the scenarios for continued program expansion. Diffusion of a program like ACT challenges government to play a nuanced role in which public endorsement and resources are used to strengthen a worthwhile service, but without suppressing flexibility and ongoing experimentation as core program values. Acceptance as a proven form of "evidence-based practice" is a critical element in the validation of ACT and other community mental health interventions that combine clinical and social features in novel ways. However, the use of conventional evidence-based research as a singular gold standard of program value narrows the range of stakeholder input, as well as the evaluation methodologies and forms of data deemed worthy of attention. Context Originating at the county level in Wisconsin in the early 1970s, Assertive Community Treatment is one of the most influential mental health programs ever developed. The subject of hundreds of research studies and recipient of enthusiastic backing from private advocacy organizations and government agencies, the program has spread widely across the United States and internationally as a package of resources and management techniques for supporting individuals with severe and chronic mental illness in the community. Today, however, ACT is associated with a rising tide of criticism challenging the program's practices and philosophy while alternative service models are advancing. Methods To trace the history of the Assertive Community Treatment movement, a diffusion-of-innovation framework was applied based on relevant concepts from public policy analysis, organizational behavior, implementation science, and other fields. In-depth review of the literature on ACT design, management, and performance also provided insight into the program's creation and subsequent evolution across different settings. Findings A number of factors have functioned to fuel and to constrain ACT diffusion. The former category includes policy learning through research; the role of policy entrepreneurs; ACT's acceptance as a normative standard; and a thriving international epistemic community. The latter category includes cost concerns, fidelity demands, shifting norms, research contradictions and gaps, and a multifactorial context affecting program adoption. Currently, the program stands at a crossroads, strained by the principle of adherence to a long-standing operational framework, on the one hand, and calls to adjust to an environment of changing demands and opportunities, on the other. Conclusions For nearly 50 years, Assertive Community Treatment has been a mainstay of community mental health programming in the United States and other parts of the world. This presence will continue, but not in any static sense. A growing number of hybrid and competing versions of the program are likely to develop to serve specialized clientele groups and to respond to consumer demands and the recovery paradigm in behavioral health care.

Policy Points Political advertising can influence which issues are public policy priorities. Population health-relevant issues were frequently referenced in televised political advertising in the 2011-2012 and 2015-2016 US election cycles, with about one-fourth of all ads aired mentioning traditional public health and health policy topics and more than half referencing broader determinants of population health. The volume of population health-relevant issues referenced in political ads varied by geography, political office, political party, and election cycle. Ads referencing broader determinants of population health (such as employment, education, or gender equality) rarely tied these determinants directly to health outcomes. Context Political discourse is one way that policymakers and candidates for public office discuss societal problems, propose solutions, and articulate actionable policies that might improve population health. Yet we know little about how politicians define and discuss issues relevant to population health in their major source of electoral communication, campaign advertisements. This study examined the prevalence of references to population health-relevant issues conveyed in campaign advertising for political office at all levels of government in the United States in 2011-2012 and 2015-2016. Understanding advertising as part of the political discourse on topics of relevance to population health yields insights about political agenda-setting and can inform efforts to shape opinion. Methods We conducted a content analysis of all English-language, candidate-related campaign advertisements aired on local broadcast, national network, and national cable television in the 2011-2012 and 2015-2016 election cycles (3,980,457 and 3,767,477 airings, respectively). We analyzed the volume of coverage in these ads about issues relevant to population health, including narrowly defined public health issues as well as a broad range of other social, economic, and environmental factors that affect population health. Findings Across both election cycles and all electoral races, 26% of campaign advertising discussed issues relevant for the narrowly defined conceptualization of public health and 57% discussed issues pertinent to topics within the more expansive population health conceptualization. There was substantial variation in population health-related content in ads across election cycles, by level of political office, political party, and geographic area. Geographic variation indicates that where a person lives affects their potential exposure to political communication about various health-related topics. Conclusions Political campaign ads in the United States frequently referenced population health-relevant content at all levels of government, although the ads rarely connected population health-relevant issues to health. Variation in volume and content of these references likely shaped public opinion and the public will to address population health-related policy.

Policy Points Recent federal proposals to use block grants or per capita caps to fund Medicaid would likely lead to cuts in Medicaid funding for health centers, which are an important source of care for Medicaid enrollees. Recent Medicaid §1115 waivers are seeking to change state-level enrollment and eligibility requirements in ways that are expected to adversely affect health center revenues. Proposed Medicaid funding cuts are expected to lead to reductions in service capacity across all health centers over the long term. State policymakers should understand the likely impacts of proposed Medicaid program changes on health centers in their states and allocate funding to help offset lost federal financing. Context In 2017, Congress considered implementing block grants or per capita caps to significantly reduce federal financing of the Medicaid program. Medicaid plays a key role in supporting health centers in their provision of care to patients with Medicaid coverage. Consequently, changes to the program could have serious implications for health centers and their ability to fulfill their mission. Methods We used a mixed-methods approach to (a) test a model simulating the effect of block grants and per capita caps on health centers' total revenues and general service capacity, and (b) augment model assumptions by using information collected from official Medicaid documents and interviews with health center leadership staff. Data came from the Uniform Data Systems (UDS), state- and county-level population projections, structured analyses of waiver documents, and interviews with health center leaders in seven states with approved or pending Medicaid §1115 waivers. Findings By 2024, in states where Medicaid coverage was expanded under the Affordable Care Act, block grant funding for Medicaid would decrease total health center revenues for the expansion population by 92%, and by 58% for traditional enrollees. In nonexpansion states, block grants would decrease health center revenues for traditional Medicaid enrollees by 38%. In expansion states, a per capita cap would, by 2024, decrease health center revenues for the expansion population by 78%, and for traditional Medicaid enrollees by 3%. The per capita cap would reduce health center revenues for traditional Medicaid enrollees in nonexpansion states by 2%. Eliminating the Medicaid expansion population would not fully compensate for health center revenue deficits in expansion states. Health center executives in all sample states expressed significant uncertainty around federal plans to reduce Medicaid funding as well as the financial implications of §1115 waiver requirements. Many interviewees anticipate cutting back on services and/or staff as a result. Conclusions Both block grants and per capita caps would have a detrimental effect on health centers. Although health center leaders anticipate a reduction in services and/or staff, the uncertainty around federal and state proposals hinders health centers from making concrete strategic plans. States should prioritize communicating changes to health centers in a timely manner and be prepared to set aside dedicated funding to address anticipated shortfalls.

Policy Points Electronic health records (EHRs) are subject to the implicit bias of their designers, which risks perpetuating and amplifying that bias over time and across users. If left unchecked, the bias in the design of EHRs and the subsequent bias in EHR information will lead to disparities in clinical, organizational, and policy outcomes. Electronic health records can instead be designed to challenge the implicit bias of their users, but that is unlikely to happen unless incentivized through innovative policy. Context Health care delivery is now inextricably linked to the use of electronic health records (EHRs), which exert considerable influence over providers, patients, and organizations. Methods This article offers a conceptual model showing how the design and subsequent use of EHRs can be subject to bias and can either encode and perpetuate systemic racism or be used to challenge it. Using structuration theory, the model demonstrates how a social structure, like an EHR, creates a cyclical relationship between the environment and people, either advancing or undermining important social values. Findings The model illustrates how the implicit bias of individuals, both developers and end-user clinical providers, influence the platform and its associated information. Biased information can then lead to inequitable outcomes in clinical care, organizational decisions, and public policy. The biased information also influences subsequent users, amplifying their own implicit biases and potentially compounding the level of bias in the information itself. The conceptual model is used to explain how this concern is fundamentally a matter of quality. Relying on the Donabedian model, it explains how elements of the EHR design (structure), use (process), and the ends for which it is used (outcome) can first be used to evaluate where bias may become embedded in the system itself, but then also identify opportunities to resist and actively challenge bias. Conclusions Our conceptual model may be able to redefine and improve the value of technology to health by modifying EHRs to support more equitable data that can be used for better patient care and public policy. For EHRs to do this, further work is needed to develop measures that assess bias in structure, process, and outcome, as well as policies to persuade vendors and health systems to prioritize systemic equity as a core goal of EHRs.

Policy Points Population health efforts to improve diabetes care and outcomes should identify social needs, support social needs referrals and coordination, and partner health care organizations with community social service agencies and resources. Current payment mechanisms for health care services do not adequately support critical up-front investments in infrastructure to address medical and social needs, nor provide sufficient incentives to make addressing social needs a priority. Alternative payment models and value-based payment should provide up-front funding for personnel and infrastructure to address social needs and should incentivize care that addresses social needs and outcomes sensitive to social risk. Context Increasingly, health care organizations are implementing interventions to improve outcomes for patients with complex health and social needs, including diabetes, through cross-sector partnerships with nonmedical organizations. However, fee-for-service and many value-based payment systems constrain options to implement models of care that address social and medical needs in an integrated fashion. We present experiences of eight grantee organizations from the Bridging the Gap: Reducing Disparities in Diabetes Care initiative to improve diabetes outcomes by transforming primary care and addressing social needs within evolving payment models. Methods Analysis of eight grantees through site visits, technical assistance calls, grant applications, and publicly available data from US census data (2017) and from Health Resources and Services Administration Uniform Data System Resources data (2018). Organizations represent a range of payment models, health care settings, market factors, geographies, populations, and community resources. Findings Grantees are implementing strategies to address medical and social needs through augmented staffing models to support high-risk patients with diabetes (e.g., community health workers, behavioral health specialists), information technology innovations (e.g., software for social needs referrals), and system-wide protocols to identify high-risk populations with gaps in care. Sites identify and address social needs (e.g., food insecurity, housing), invest in human capital to support social needs referrals and coordination (e.g., embedding social service employees in clinics), and work with organizations to connect to community resources. Sites encounter challenges accessing flexible up-front funding to support infrastructure for interventions. Value-based payment mechanisms usually reward clinical performance metrics rather than measures of population health or social needs interventions. Conclusions Federal, state, and private payers should support critical infrastructure to address social needs and incentivize care that addresses social needs and outcomes sensitive to social risk. Population health strategies that address medical and social needs for populations living with diabetes will need to be tailored to a range of health care organizations, geographies, populations, community partners, and market factors. Payment models should support and incentivize these strategies for sustainability.

POLICY POINTS: Dissemination of Choosing Wisely guidelines alone is unlikely to reduce the use of low‐value health services. Interventions by health systems to implement Choosing Wisely guidelines can reduce the use of low‐value services. Multicomponent interventions targeting clinicians are currently the most effective types of interventions. CONTEXT: Choosing Wisely aims to reduce the use of unnecessary, low‐value medical services through development of recommendations related to service utilization. Despite the creation and dissemination of these recommendations, evidence shows low‐value services are still prevalent. This paper synthesizes literature on interventions designed to reduce medical care identified as low value by Choosing Wisely and evaluates which intervention characteristics are most effective. METHODS: We searched peer‐reviewed and gray literature from the inception of Choosing Wisely in 2012 through June 2019 to identify interventions in the United States motivated by or using Choosing Wisely recommendations. We also included studies measuring the impact of Choosing Wisely on its own, without interventions. We developed a coding guide and established coding agreement. We coded all included articles for types of services targeted, components of each intervention, results of the intervention, study type, and, where applicable, study quality. We measured the success rate of interventions, using chi‐squared tests or Wald tests to compare across interventions. FINDINGS: We reviewed 131 articles. Eighty‐eight percent of interventions focused on clinicians only; 48% included multiple components. Compared with dissemination of Choosing Wisely recommendations only, active interventions were more likely to generate intended results (65% vs 13%, p < 0.001) and, among those, interventions with multiple components were more successful than those with one component (77% vs 47%, p = 0.002). The type of services targeted did not matter for success. Clinician‐based interventions were more effective than consumer‐based, though there is a dearth of studies on consumer‐based interventions. Only 17% of studies included a control arm. CONCLUSIONS: Interventions built on the Choosing Wisely recommendations can be effective at changing practice patterns to reduce the use of low‐value care. Interventions are more effective when targeting clinicians and using more than one component. There is a need for high‐quality studies that include active controls.

Policy Points The increased use of nurse practitioners represents a viable policy option to address continuing access-to-care deficiencies across the United States, but state scope-of-practice laws limit the ability of nurse practitioners to deliver health care. Groups in favor of restrictive scope-of-practice laws have argued that relaxing these laws will lead to increases in opioid prescriptions during an already severe opioid crisis, implicating patient safety concerns. An examination of a data set of 1.5 billion opioid prescriptions demonstrates that relaxing nurse practitioner scope-of-practice laws generally reduces opioid prescriptions. This evidence supports eliminating restrictive scope-of-practice laws that currently govern nurse practitioners in many states. Context As many parts of the United States continue to face physician shortages, the increased use of nurse practitioners (NPs) can improve access to care. However, state scope-of-practice (SOP) laws limit the ability of NPs to provide care by restricting the services they can provide and often requiring physician supervision of their practices. One important justification for the continuation of these restrictive SOP laws is preventing the overprescription of certain medications, particularly opioids. Methods This study examined a data set of approximately 1.5 billion individual opioid prescriptions between 2011 and 2018, which were aggregated to the individual provider-year level. A series of difference-in-differences regression models was estimated to examine the association between laws allowing NPs to practice independently and opioid prescribing patterns among physicians and NPs. Opioid prescriptions were measured in total annual morphine milligram equivalents (MMEs) prescribed by individual providers. Findings Across all NPs and physicians, independent NP practice was associated with a statistically significant decline of 6%, 2%, 3%, 7%, and 5% in total annual MMEs prescribed to commercially insured, cash-paying, Medicare, government-assistance, and all patients, respectively. Medicaid patients saw no statistically significant change in annual MMEs. Across all payers, NPs generally increase and physicians generally decrease the number of opioids they prescribe following a grant of NP independence. These counterbalancing changes result in an overall net decline in MMEs. Conclusions No evidence supports the contention that allowing NPs to practice independently increases opioid prescriptions. The results support policy changes that allow NPs to practice independently.

Context Methods Findings Conclusions Policy Points Telehealth has many potential advantages during an infectious disease outbreak such as the COVID‐19 pandemic, and the COVID‐19 pandemic has accelerated the shift to telehealth as a prominent care delivery mode Not all health care providers and patients are equally ready to take part in the telehealth revolution, which raises concerns for health equity during and after the COVID‐19 pandemic Without proactive efforts to address both patient‐ and provider‐related digital barriers associated with socioeconomic status, the wide‐scale implementation of telehealth amid COVID‐19 may reinforce disparities in health access in already marginalized and underserved communities To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them Telehealth has many potential advantages during an infectious disease outbreak such as the COVID‐19 pandemic, and the COVID‐19 pandemic has accelerated the shift to telehealth as a prominent care delivery mode Not all health care providers and patients are equally ready to take part in the telehealth revolution, which raises concerns for health equity during and after the COVID‐19 pandemic Without proactive efforts to address both patient‐ and provider‐related digital barriers associated with socioeconomic status, the wide‐scale implementation of telehealth amid COVID‐19 may reinforce disparities in health access in already marginalized and underserved communities To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them The COVID‐19 pandemic has catalyzed fundamental shifts across the US health care delivery system, including a rapid transition to telehealth Telehealth has many potential advantages, including maintaining critical access to care while keeping both patients and providers safe from unnecessary exposure to the coronavirus However, not all health care providers and patients are equally ready to take part in this digital revolution, which raises concerns for health equity during and after the COVID‐19 pandemic The study analyzed data about small primary care practices’ telehealth use and barriers to telehealth use collected from rapid‐response surveys administered by the New York City Department of Health and Mental Hygiene's Bureau of Equitable Health Systems and New York University from mid‐April through mid‐June 2020 as part of the city's efforts to understand how primary care practices were responding to the COVID‐19 pandemic following New York State's stay‐at‐home order on March 22 We focused on small primary care practices because they represent 40% of primary care providers and are disproportionately located in low‐income, minority or immigrant areas that were more severely impacted by COVID‐19 To examine whether telehealth use and barriers differed based on the socioeconomic characteristics of the communities served by these practices, we used the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to stratify respondents as being in high‐SVI or low‐SVI areas We then characterized respondents’ telehealth use and barriers to adoption by using means and proportions with 95% confidence intervals In addition to a primary analysis using pooled data across the five waves of the survey, we performed sensitivity analyses using data from respondents who only took one survey, first wave only, and the last two waves only While all providers rapidly shifted to telehealth, there were differences based on community characteristics in both the primary mode of telehealth used and the types of barriers experienced by providers Providers in high‐SVI areas were almost twice as likely as providers in low‐SVI areas to use telephones as their primary telehealth modality (41 7% vs 23 8%;P < 001) The opposite was true for video, wh ch was used as the primary telehealth modality by 18 7% of providers in high‐SVI areas and 33 7% of providers in low‐SVI areas (P

Policy Points Preventive measures such as the national lockdown in Italy have been effective in slowing the spread of COVID-19. However, they also had psychological and economic impacts on people's lives, which should not be neglected as they may reduce citizens' trust and compliance with future health mandates. Engaging citizens in their own health management and in the collaboration with health care professionals and authorities via the adoption of a collaborative approach to health policy development is fundamental to fostering such measures' effectiveness. Psychosocial analysis of citizens' concerns and emotional reactions to preventive policies is important in order to plan personalized health communication campaigns. CONTEXT: Because of the COVID-19 pandemic, between February 23 and March 8, 2020, some areas of Italy were declared "red zones," with citizens asked to stay home and avoid unnecessary interpersonal contacts. Such measures were then extended, between March 10 and May 4, 2020, to the whole country. However, compliance with such behaviors had an important impact on citizens' personal, psychological, and economic well-being. This could result in reduced trust in authorities and lowered compliance. Keeping citizens engaged in their own health and in preventive behaviors is thus a key strategy for the success of such measures. This paper presents the results from a study conducted in Italy to monitor levels of people's health engagement, sentiment, trust in authorities, and perception of risk at two different time points. METHODS: Two independent samples (n = 968 and n = 1,004), weighted to be representative of the adult Italian population, were recruited in two waves corresponding to crucial moments of the Italian COVID-19 epidemic: between February 28 and March 4 (beginning of "phase 1," after the first regional lockdowns), and between May 12 and May 18 (beginning of "phase 2," after the national lockdown was partially dismissed). Respondents were asked to complete an online survey with a series of both validated measures and ad hoc items. A series of t-tests, general linear models, and contingency tables were carried out to assess if and how our measures changed over time in different social groups. FINDINGS: Although sense of self and social responsibility increased between the two waves, and trust toward authorities remained substantially the same, trust in science, consumer sentiment, and health engagement decreased. Our results showed that while both the level of general concern for the emergency and the perceived risk of infection increased between the two waves, in the second wave our participants reported being more concerned for the economic consequences of the pandemic than the health risk. CONCLUSIONS: The potentially disruptive psychological impact of lockdown may hamper citizens' compliance with, and hence the effectiveness of, behavioral preventive measures. This suggests that preventive measures should be accompanied by collaborative educational plans aimed at promoting people's health engagement by making citizens feel they are partners in the health preventive endeavor and involved in the development of health policies.

Policy Points Private health insurance (PHI) in France has been facing critical changes over the past 30 years. A complementary and voluntary scheme, it has been historically dominated by nonprofit entities. However, the share of for-profit insurance companies in the sector has significantly increased. Nonprofit firms also changed their strategies and mimicked some for-profit behaviors. The present paper argues that this process is a result of the conflict-provoking coevolution of the insurance and health care sectors. Trying to improve the regulation of the insurance industry as whole, two European directives first jeopardized the business model of nonprofit entities. Then, two national reforms designed to improve health coverage significantly increased competition among insurers, notably in the area of corporate-level contracts. Decoupling the insurance and health care sectors has become a major source of policy feedback and unexpected outcomes of reforms affecting the very organization of PHI. Context In France, private health insurance (PHI) has an exceptionally high level of coverage and accounts for 13.7% of health expenditures. A complementary and voluntary scheme, it has been historically dominated by nonprofit, mutual benefit societies. Over the past 20 years, however, the market share of for-profit insurance companies has increased by 47%. Financialization of the field developed, and competition based on new risk management strategies also increased. The broad aim of this paper is to characterize and to elucidate the causes of this trend. More specifically, we are interested in how and to what extent a series of supranational and national policies contributed to this situation. Method Our data come from three sources. We first reviewed documents published by health insurers, government reports, and newspaper articles. We then conducted two semistructured interview campaigns between September 2017 and May 2018. The first mostly covered private and public actors and their involvement in European Union (EU) policymaking (n = 21). The second series of interviews was conducted with another group of actors directly involved at the French level (n = 16). Findings Our findings support preliminary observations. PHI in France, we argue, is indeed facing a development of competition and marketlike instruments. Four major policies (two EU directives and two national reforms) played a significant role in this outcome. Surprisingly, however, it has never been the purpose of legislators and policymakers: while EU directives created a regulatory framework for insurance activities within the Single Market, policies adopted at the national level initially aimed at improving health coverage. We show that it is the interactions and the noncoordination among all of these policies that explain their unexpected outcome. Conclusions The trend described in this paper is twofold. The first is Europeanization, as PHI in France is increasingly affected by EU legislation. Since this framework tends to favor larger firms and for-profit companies, a reduction in statutory coverage can no longer be considered a quasi-neutral transfer from (publicly owned) social security to nonprofit providers. At the same time, PHI is shifting toward collectivization: as competition increases, complementary health coverage is becoming gradually standardized and based at the corporate level. Together, these changes are likely to reduce freedom of choice and individual welfare, an assumption supported by studies published on the most recent period.

Policy Points We offer the first systematic conceptual framework for analyzing the operation of mandatory vaccination policies. Our multicomponent framework facilitates synthesis judgments on single issues of pressing concern to policymakers, in particular, how mandatory vaccination policies motivate people to vaccinate. We consider the impact of each component of our framework on persons who remain unvaccinated for different reasons, including complacency, social disadvantage, and more or less committed forms of refusal. Context In response to outbreaks of vaccine-preventable disease and increasing rates of vaccine refusal, some political communities have recently implemented coercive childhood immunization programs, or they have made existing childhood immunization programs more coercive. Many other political communities possess coercive vaccination policies, and others are considering developing them. Scholars and policymakers generally refer to coercive immunization policies as "vaccine mandates." However, mandatory vaccination is not a unitary concept. Rather, coercive childhood immunization policies are complex, context-specific instruments. Their legally and morally significant features often differ, and they are imposed by political communities in varying circumstances and upon diverse populations. Methods In this paper, we introduce a taxonomy for classifying real-world and theoretical mandatory childhood vaccination policies, according to their scope (which vaccines to require), sanctions and severity (which kind of penalty to impose on vaccine refusers, and how much of that penalty to impose), and selectivity (how to enforce or exempt people from vaccine mandates). Findings A full understanding of the operation of a vaccine mandate policy (real or potential) requires attention to the separate components of that policy. However, we can synthesize information about a policy's scope, sanctions, severity, and selectivity to identify a further attribute-salience-which identifies the magnitude of the burdens the state imposes on those who are not vaccinated. Conclusion Our taxonomy provides a framework for forensic examination of current and potential mandatory vaccination policies, by focusing attention on those features of vaccine mandates that are most relevant for comparative judgments.

Policy Points The US Food and Drug Administration (FDA) has in recent years allowed onto the market several drugs with limited evidence of safety and effectiveness, provided that manufacturers agree to carry out additional studies while the drugs are in clinical use. Studies suggest that these postmarketing requirements (PMRs) frequently lack transparency, are subject to delays, and fail to answer the questions of greatest clinical importance. Yet, none of the literature speaks directly to the challenges that the FDA-as a regulatory institution-encounters in enforcing PMRs. Through a series of interviews with FDA leadership, this article analyzes and situates those challenges in the midst of political threats to the FDA's public health mandate. CONTEXT Modern pharmaceutical regulation is premised on a rigorous examination of a drug's safety and effectiveness prior to its lawful sale. However, since the 1990s, the US Food and Drug Administration (FDA) has gradually shifted to a model of "lifecycle" regulation that increasingly relies on postmarketing requirements (PMRs) to encourage studies of drug safety and effectiveness following regulatory approval. This article examines the range of legal, institutional, and political challenges that FDA faces in the context of lifecycle regulation. METHODS Document-based legal and policy analysis was combined with a set of semistructured interviews of current and former FDA officials (n = 23) in order to explore the implications of the FDA's use of PMRs. The median interview time per official was 61 minutes, with a range of 24 to 227 minutes. All of the officials interviewed occupied positions of leadership and influence within the FDA, such as directors of an FDA center or office, key legal counsel on agency-wide policy initiatives, and the commissioner of the FDA. FINDINGS Insufficient resources and coordination within the FDA, inadequate legal authorities, and the political economy of withdrawing an approved indication in the face of opposition from companies and patients all contribute to the observed shortcomings in the FDA's use and enforcement of PMRs. Further, the FDA is fully aware of these challenges, yet is seemingly resigned to and resistant to criticism of its use of PMRs. CONCLUSIONS This study of the FDA's shift toward lifecycle regulation reveals not simply an agency in transition, but rather an agency on guard against a set of larger political threats to its mandate. This can be characterized as a state of institutional incumbency in which the agency is engaged in an effort to reproduce key features of the regulatory system-in concert with regulated industries and others-while simultaneously sanctioning significant changes to the regulatory standards the FDA has long applied, to the detriment of public health.

Policy Points Tobacco industry denormalization is a key strategy for tobacco control that has been formalized in the WHO Framework Convention on Tobacco Control. International trade and investment laws are a potential threat to tobacco industry denormalization because they do not automatically incorporate denormalization and, in theory, treat tobacco firms like other commercial interests. Countries that seek to defend tobacco control policies against international trade and investment challenges need to have good governance in two senses: good governance as understood by tribunals and good-enough governance to manage the processes and requirements that enable policies to survive international challenges. Context Tobacco industry denormalization (TID), portraying tobacco product manufacturers as a deadly industry, is a major strategy for public health advocates. Using this strategy, activists around the world have successfully pushed for governments to enact tobacco control regulations, including the unprecedented international Framework Convention on Tobacco Control (FCTC). TID has been a distinctive legal and political strategy that has affected the place of tobacco in law and has both inspired and constrained those who would imitate the strategy in other areas of regulation, such as diet or alcohol. It is therefore a case study in the creation of a distinctive legal approach and of threats to that approach from the changing role of world trade and investment law, which creates a new set of venues that tobacco industry advocates can use to redefine tobacco as a normal good and to seek out "fair and equitable treatment" for their industry. Methods I review legal and policy documents pertaining to two major challenges to tobacco control policies in Australia and Uruguay aimed at controlling industry branding. Findings International trade and investment law challenges TID and raises fundamental questions about the role of the state in protecting public health. Recent trade disputes involving Uruguay and Australia illustrate this dynamic. Despite losing high-court challenges against packaging regulations in both countries, tobacco firms were still able to challenge states in a different way, through international trade and investment agreements. This article identifies the industry's strategies and the responses of those seeking to avoid renormalizing tobacco as a part of world trade. In particular, states must demonstrate that their tobacco control policies satisfy standards set by tribunals, which include standards of good governance, and they must prepare their policies in a way that reduces legal risk and requires good governance. Conclusions Although TID has strengthened the hand of tobacco control advocates, TID strategies alone are not sufficient to defend public regulations against extraterritorial legal challenges in an arena that resists the basic TID technique of singling out a particular industry. Public health advocates might also note the FCTC's aid in helping governments defend themselves against these challenges and consider similar international instruments for other areas.

POLICY POINTS: Individuals with behavioral health (BH) conditions comprise a medically complex population with high costs and high health care needs. Considering national shortages of BH providers, primary care providers serve a critical role in identifying and treating BH conditions and making referrals to BH providers. States are increasingly seeking ways to address BH conditions among their residents. States funded by the Centers for Medicare and Medicaid Services under the first round of the State Innovation Models (SIM) Initiative all invested in BH integration. States found sharing data among providers, bridging professional divides, and overcoming BH provider shortages were key barriers. Nonetheless, states made significant strides in integrating BH care. Beyond payment models, a key catalyst for change was facilitating informal relationships between BH providers and primary care physicians. Infrastructure investments such as promoting data sharing by connecting BH providers to a health information exchange and providing tailored technical assistance for both BH and primary care providers were also important in improving integration of BH care. CONTEXT: Increasing numbers of states are looking for ways to address behavioral health (BH) conditions among their residents. The first round of the State Innovation Models (SIM) Initiative provided financial and technical support to six states since 2013 to test the ability of state governments to lead health care system transformation. All six SIM states invested in integration of BH and primary care services. This study summarizes states’ progress, challenges, and lessons learned on BH integration. Additionally, the study reports impacts on expenditure, utilization, and quality‐of‐care outcomes for persons with BH conditions across four SIM states. METHODS: We use a mixed‐methods design, drawing on focus groups and key informant interviews to reach conclusions on implementation and quantitative analysis using Medicaid claims data to assess impact. For three Medicaid accountable care organization (ACO) models funded under SIM, we used a difference‐in‐differences regression model to compare outcomes for model participants with BH conditions and an in‐state comparison group before‐and‐after model implementation. For the behavioral health home (BHH) model in Maine, we used a pre‐post design to assess how outcomes for model participants changed over time. FINDINGS: Informal relationship building, tailored technical assistance, and the promotion of data sharing were key factors in making progress. After three years of implementation, the growth in total expenditures was less than the comparison group by $128 (−$253, −$3; p < 0.10) and $62 (−$87, −$36; p < 0.001) per beneficiary per month for beneficiaries with BH conditions attributed to an ACO in Minnesota and Vermont, respectively. Likewise, there were reductions in emergency department use for ACO participants in all three states after two to four years of implementation. However, there was no improvement in BH‐related quality metrics for ACO beneficiaries in all three states. Although participants in the BHH model had increased expenditures after two years of implementation, use of primary care and specialty care services increased by 3% and 8%, respectively, and antidepressant medication adherence also improved. CONCLUSIONS: The SIM Round 1 states made considerable progress in integrating BH and primary care services, and there were promising findings for all models. Taken together, there is some evidence that Medicaid payment models can improve patterns of care for beneficiaries with BH conditions.