Search

The COVID-19 pandemic of 2020 was one of the rare events that shocked almost every world government simultaneously, thus creating an unusual opportunity to understand how political institutions shape policy decisions. There have been many analyses of what governments did. We focus instead on what they could do, focusing on the institutional politics of agency – how institutions empower rather than how they constrain, and how they affect public policy decisions. We examine public health measures in the first wave (March-September 2020) in Brazil, India, and the U.S. to understand how the interplay of institutions in a complex federal context shaped COVID-19 policy-responses. We find similar patterns of concentrated federal executive agency with limited constraints. In each case, when federal leadership failed public health policy responses, federated, subnational states were left to compensate for these inefficiencies without necessary resources. [ABSTRACT FROM AUTHOR]

Oppression and inequality, as critical social and structural determinants of health, are key threats to public health. Democratic stability provides institutional measures to mitigate oppression and inequality. We investigate trends in democratic backsliding in the Organization for Economic Co‐operation and Development (OECD) nations, overall, and compare trends in backsliding among specific indicators of democracy relevant to public health based on protections against oppression and inequality. We leverage a comprehensive, longitudinal, data set (V‐DEM), capturing key indicators of democracy in OECD nations from 2010 to 2020. Indicators were selected from the scholarly literature on democracy and health for their effects on oppression and inequality. We observe trends over time in democratic stability among OECD nations, overall, and then compare trends in democratic stability or backsliding across OECD nations within categories of democratic indicators established to mitigate oppression and inequality. Democracy is declining across all OECD nations. Broad democratic declines are shown between types of OECD member states. Country income is not necessarily protective for democratic stability. We find specific declines in two measures with immediate implications for public health—Civil Liberties and Integrity of the Courts—across at least half of all OECD nations and a particularly alarming level of change in the United States. Politics shape and limit public health. Declining components of democracy can have both short‐ and long‐term consequences for population health by increasing inequality and reducing mechanisms to protect against oppressive tactics. Public health can play an important role in improving democracy by strengthening accountability. Key points: Democratic declines have acute and long‐term consequences for population health by increasing inequality and reducing mechanisms to protect against oppressive tactics.Democracy is declining across all the Organization for Economic Co‐operation and Development (OECD) nations, though with significant variation between countries.Middle‐income countries show more volatility in their levels of democratic advance and decline, but the United States stands out among the richest countries for its level of democratic backsliding.Civil Liberties and Integrity of the Courts—two democratic indicators with immediate implications for public health are declining across at least half of all OECD nations. [ABSTRACT FROM AUTHOR]

COVID‐19 is not the first, nor the last, public health challenge the US political system has faced. Understanding drivers of governmental responses to public health emergencies is important for policy decision‐making, planning, health and social outcomes, and advocacy. We use federal political disaster‐aid debates to examine political factors related to variations in outcomes for Puerto Rico, Texas, and Florida after the 2017 hurricane season. Despite the comparable need and unprecedented mortality, Puerto Rico received delayed and substantially less aid. We find bipartisan participation in floor debates over aid to Texas and Florida, but primarily Democrat participation for Puerto Rican aid. Yet, deliberation and participation in the debates were strongly influenced by whether a state or district was at risk of natural disasters. Nearly one‐third of all states did not participate in any aid debate. States' local disaster risk levels and political parties' attachments to different racial and ethnic groups may help explain Congressional public health disaster response failures. These lessons are of increasing importance in the face of growing collective action problems around the climate crisis and subsequent emergent threats from natural disasters. Key points: Our results suggest that the deaths of thousands of Americans may not be enough to mobilize congressional participation in disaster aid deliberations, and that legislators may be more incentivized to participate in debates if they perceive disaster risk to their districts.Where some states have more advocacy for federal disaster aid than others, disparities in disaster aid relief and subsequent outcomes may be exacerbated.Institutional barriers may further exacerbate participatory inequality in disaster aid deliberations, such as no voting membership for U.S. territories. Institutional constraints and the strong relationship between disaster risk and legislative participation in aid debates compared to mortality may reduce accountability for federal disaster response failures. [ABSTRACT FROM AUTHOR]

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