The Paradoxical Politics of Community Health Centers from the Great Society to the COVID-19 Pandemic.

CONTEXT: Though community health centers (CHCs) arose in the 1960s as part of a Democratic policy push committed to social justice, subsequent support has been shaped by a paradoxical politics wherein Republican and Democratic support for CHCs continually morphed in response to changes in the health policy landscape. METHODS: Drawing on the CHC literature and empirical examples from first-hand accounts and reporting, we explain CHCs' curious historical development from 1965 to present. FINDINGS: Since their inception, CHCs have received differing levels of support due to a paradoxical politics that tell us much about CHC policy history. Though the CHC program began as a Democratic vision, both Republicans and Democrats have calibrated their support for CHCs in response to a broader set of political considerations, from anti-welfare policy commitments to aspirations of establishing a national health care plan. CONCLUSIONS: CHCs have proven to be a politically malleable policy tool within the broader context of American health care policy. While the COVID-19 pandemic raised new questions about CHCs' sustainability and future, CHCs will continue to play a critical role not only providing health care access to underserved populations, but as an attractive bipartisan policy option within the larger framework of U.S. health policy.

Effects of the Affordable Care Act Medicaid Expansions on Mental Health During the COVID-19 Pandemic in 2020-2021.

To examine whether previous Affordable Care Act (ACA) Medicaid expansions had an added effect on the mental health of low-income adults during the COVID-19 pandemic in 2020 and 2021. We use the 2017-2021 Behavioral Risk Factor Surveillance System (BRFSS) data. We use an event study difference-in-differences model to compare the number of days in poor mental health in the past 30 days and the likelihood of frequent mental distress among 18 to 64 year old individuals with household incomes below 100% of the federal poverty level who participated in BRFSS in one of the surveys from 2017 to 2021 and who resided in states that expanded Medicaid by 2016 or states that had not expanded by 2021. We also examine the heterogeneity of the expansion effects across subpopulation groups. We find some evidence that the Medicaid expansion was associated with better mental health during the pandemic for adults younger than 45, females, and non-Hispanic Black and other non-Hispanic non-White individuals. There is some evidence of an added benefit to mental health from Medicaid expansion status during the pandemic for some subgroups among low-income adults, suggesting potential health benefits from Medicaid eligibility during public health and economic crises.

Enhancing Federal Revenue under the American Rescue Plan Act: An Opportunity to Bolster State Medicaid Home and Community-Based Services Programs.

The American Rescue Plan Act (ARPA) includes a one-year 10 percentage point increase in the Federal Medical Assistance Percentage for Medicaid-funded home and community-based services (HCBS). The goal is to strengthen state efforts to help older adults and people with disabilities live safely in their homes and communities rather than in institutional settings during the COVID-19 pandemic. This essay provides a detailed description and analysis of this provision, including issues state governments need to consider when expending the additional federal revenue provided. It also draws lessons from the Affordable Care Act's Balancing Incentive Program to suggest insights for the potential of ARPA to promote further growth in Medicaid HCBS programs. It argues that key to success will be consultation with community stakeholders under the auspices of clear and frequent federal guidance and the development of concrete plans with which to expend the additional revenues in the most effective way possible in the limited time frame provided. The essay concludes by highlighting the importance of instituting strategies and processes for maximizing enhanced federal matching funds under ARPA in preparation for subsequent availability of substantial additional federal resources targeting Medicaid HCBS under other proposed initiatives.

Changing English Local Authority Duties by the Adoption of Easements in the COVID-19 Pandemic, Findings from an Interview-Based Study

This article reports findings from a study on the effect of the adjustments or 'easements' that were made to the 2014 Care Act when measures to manage the impact of COVID-19 were introduced in England in 2020. Only eight local authorities (LAs) implemented the changes permitted. The experiences of five are explored in this article. Data were collected in 2021 through interviews with Directors of Adult Social Services and other senior managers in these LAs and analysed using a thematic approach. Participants referred to the challenges under which they were working pre-pandemic, including resource pressures and problems recruiting and retaining staff. Despite the conditions attached to adopting easements these LAs had done so because of the uncertainties they were facing. All ceased to use them within a short time because they could manage without them. They had been shocked by the concerted opposition to easements and the time necessitated in responding to this. They contrasted their experiences with the apparent ease with which NHS colleagues had been able to change their practices. The experiences of these LAs may contribute to planning for the continuity of social care in any future emergency.

RISKY BUSINESS: HEALTH CARE BEFORE AND AFTER TRUMP

This chapter focuses on the Trump administration's health policies, with an emphasis on its efforts to repeal the Affordable Care Act and its response to the COVID-19 pandemic. It assesses those policies both in the context of the administration's broader goals and motivations, and in the context of systemic deficits and deficiencies in American health policy. I argue that failures of health policy and health security in the face of the pandemic reflect those longstanding weaknesses, much more so than the administration's actions (or inaction). © 2023 by Emerald Publishing Limited All rights of reproduction in any form reserved.

Financial Security: Protecting the Health of Consumers

Medical expenses and health insurance are important dimensions of policy and research debates in protecting the health of consumers. This chapter provides an overview of the large and growing body of literature exploring the determinants of medical expenses and health insurance in protecting the health of consumers in the context of financial security. This chapter highlights analyses of two distinct sets of evidence: (a) studies of medical expenses and health insurance;and (b) studies of job loss and financial insecurity, particularly the inability to pay medical bills resulting from the Covid-19 pandemic. As discussed in this chapter, implementing health policies and regulations plays a critical role in protecting the health of consumers. Thus, the chapter addresses recent U.S. legislation such as the Affordable Care Act (ACA) and the No Surprises Act, which could protect consumers both medically and financially. Reviewing an extensive body of literature on these issues, the chapter concludes with implications for both policy and practice, as well as for future research avenues. © 2022 Walter de Gruyter GmbH, Berlin/Boston.

Association between state Medicaid expansion status and health outcomes during the COVID-19 pandemic.

OBJECTIVE: To assess post-COVID-19 changes in insurance coverage, health behaviors, and self-assessed health among low-income, non-elderly adults by state Medicaid expansion status. DATA SOURCES: We used nationally representative survey data from the 2016 through 2020 Behavioral Risk Factor Surveillance System (BRFSS). The sample was restricted to adults aged 19-64 with household income below 138 percent of the federal poverty level (N = 179,135). STUDY DESIGN: We examined a broad set of outcomes related to coverage, health behaviors, and self-assessed health available in the BRFSS. We used a difference-in-differences model to compare changes in outcomes for individuals living in the 35 states and DC that expanded Medicaid under the Affordable Care Act to those in the 15 non-expansion states before and after the COVID-19 pandemic commenced in March 2020. DATA COLLECTION/EXTRACTION METHODS: N/A. PRINCIPAL FINDINGS: We found that the expansions provided some protection for low-income people during the pandemic. In 2020, relative to earlier years, people in expansion states were more likely to report very good or excellent health (4.9 percentage points, 95%CI = 0.022, 0.076; p < 0.01) and physical health (-0.393 days of poor physical health in the past month, 95%CI = -0.714, -0.072; p < 0.05), lower rates of smoking (-1.9 percentage points, 95%CI = -0.041, 0.004; p < 0.10) and heavy drinking (-1.4 percentage points, 95%CI = -0.025, -0.004; p < 0.01), and higher flu vaccination rates (2.8 percentage points, 95%CI = 0.005, 0.051; p < 0.05) than those in non-expansion states. These benefits were particularly salient for Black and Hispanic individuals. We found no significant differences in insurance coverage, exercise, obesity, and self-assessed mental health between expansion and non-expansion states for the overall low-income sample. However, the expansion was associated with greater insurance coverage for Hispanic adults during the pandemic. CONCLUSIONS: Investments in public health through expanding Medicaid may shield low-income populations from some of the health ramifications of public health emergencies.

COVID-19-related Medicaid enrollment in Medicaid expansion and non-expansion states.

RESEARCH OBJECTIVE: To explore whether expanded Medicaid helps mitigate the relationship between unemployment due to COVID and being uninsured. Unanticipated unemployment spells are generally associated with disruptions in health insurance coverage, which could also be the case for job losses during the COVID-19 pandemic. Expanded access to Medicaid may insulate some households from long uninsurance gaps due to job loss. DATA SOURCE: Phase 1 of the Census Bureau's Experimental Household Pulse Survey covering April 23, 2020-July 21, 2020. STUDY DESIGN: We compare differences in health insurance coverage source and status linked to recent lob losses attributable to the COVID-19 pandemic in states that expanded Medicaid against states that did not expand Medicaid. DATA COLLECTION/EXTRACTION METHODS: Our analytical dataset was limited to 733,181 non-elderly adults aged 20-64. PRINCIPAL FINDINGS: Twenty-six percent of our study sample experienced an income loss between March 13, 2020, and the time leading up to the survey-16% experienced job losses (e.g., layoff, furlough) due to the COVID-19 crisis, and 11% had other reasons they were not working. COVID-linked job losses were associated with a 20 (p < 0.01) percentage-point (PPT) lower likelihood of having employer-sponsored health insurance (ESI). Relative to persons in states that did not expand Medicaid, persons in Medicaid expansion states experiencing COVID-linked job losses were 9 PPT (p < 0.01) more likely to report having Medicaid and 7 PPT (p < 0.01) less likely to be uninsured. The largest increases in Medicaid enrollment were among people who, based on their 2019 incomes, would not have qualified for Medicaid previously. CONCLUSIONS: Our findings suggest that expanded Medicaid eligibility may allow households to stabilize health care needs and they should become detached from private health coverage due to job loss during the pandemic. Households negatively affected by the pandemic are using Medicaid to insure themselves against the potential health risks they would incur while being unemployed.

COVID-19 and African Americans: A problem decades in the making

COVID-19 has exposed health care disparities long known and discussed in medical and public policy literature. While there have been many discussions regarding our "offense" - how to attack a global pandemic (vaccines, treatment algorithms, etc), there has also been a renewed interest regarding our "defense" (limiting exposure, strengthening the host) - i.e., how to protect our most vulnerable populations. In June 2020, The U.S. Health and Human Services Department announced a $40 million, three-year partnership with the Morehouse School of Medicine to focus on this topic. As described by Danie Dawes (director of Morehouse's Satcher Health Leadership Institute), this national COVID-19 resiliency network (NCRN) will focus on at-risk communities and social determinants of health. With a few policy changes this "perfect storm" (deadly virus + high exposure + overly susceptible hosts) might not have occurred, so it is imperative that we learn from mistakes of the past and act quickly so that lives may be saved. While we work on vaccines, better testing options and social distancing - our defense for the next pandemic can begin now by creating a healthier society for us all. Health equity is needed now more than ever.

Utilization of preventive services by women enrolled in the Affordable Care Act's Health Insurance Marketplace.

The Health Insurance Marketplace has offered access to private health insurance coverage for over 10 million Americans, including previously uninsured women. Per Affordable Care Act requirements, Marketplace plans must cover preventive services without patient cost-sharing in the same way as in employer-sponsored insurance (ESI). However, no study has evaluated whether the utilization of preventive services is similar between Marketplace enrollees and ESI enrollees. Using the Medical Expenditure Panel Survey data for 2014-2016, we identified working-age women with Marketplace plans (n = 792, N = 2,567,292) and ESI (n = 13,100, N = 52,557,779). We compared the two groups' receipt rates of five evidence-based preventive services: blood pressure screening, influenza vaccine, Pap test, mammogram, and colorectal cancer screening. Unadjusted results showed marketplace enrolled women had significantly lower odds of influenza vaccination, Pap test, and mammogram. However, after controlling for other factors, Marketplace insurance was not associated with lower receipt rates of preventive services, except for influenza vaccination (Adjusted OR = 0.64; 95% CI = 0.50-0.82). Regardless of an individual's private insurance type, higher educational attainment and having a usual source of medical care showed the strongest association with the receipt of all investigated preventive services. With the increased role of the Marketplace as a safety net in the COVID-19 pandemic, more research and outreach efforts should be made to facilitate access to preventive services for its enrollees.

Disparities in Health Care Delivery Systems.

Racial disparities in health care systems exist in all phases of health care delivery. The Affordable Care Act has been unable to completely mitigate disparities in health care as the root cause (ie, socioeconomic inequality) remains unaddressed. Uninsured status, lack of transportation, high costs, health literacy, provider unavailability, lack of trust in the health system, and implicit bias block minority populations from obtaining deserved quality care. With the COVID-19 crisis, increased sensitivity and development of innovative approaches to provide accessibly and quality health care are necessary.

A Eulogy for Jane Robinson: A Social Autopsy of Uncare Policies.

Shortly after losing her health insurance in 2018, Jane Robinson died of a treatable respiratory infection. This article argues that Jane's death occurred at the nexus of two different approaches to care: the necropolitics of uncare and the micropolitics of generative care labor. Both of these approaches to care increased Jane's health and social vulnerability, in turn quickening her death. We adopt the necropolitics of uncare framework to identify and name the harmful policies and attitudes of disregard that control access to life saving medical care. In the micropolitics of care in Jane's life, she became the safety net for others, which left little over when her health began to deteriorate. This social autopsy reveals that her care networks were insufficient to undo the uncare enshrined in state policy. Jane's unnecessary death foreshadowed the excess mortality that the United States has experienced from COVID-19.

Federalism Complicates the Response to the COVID-19 Health and Economic Crisis: What Can Be Done?

Federalism has complicated the US response to the novel coronavirus. States' actions to address the pandemic have varied widely, and federal and state officials have provided conflicting messages. This fragmented approach has surely cost time and lives. Federalism will shape the long-term health and economic impacts of COVID-19, including plans for the future, for at least two reasons: First, federalism exacerbates inequities, as some states have a history of underinvesting in social programs, especially in certain communities. Second, many of the states with the deepest needs are poorly equipped to respond to emergencies due to low taxes and distrust of government, leading to inadequate infrastructure. These dynamics are not new, but they have been laid bare by this crisis. What can policy makers do to address the inequities in health and economic outcomes that federalism intensifies? The first section of this article offers a case study of the Mississippi Delta to illustrate the role of federalism in perpetuating the connection between place, health, and economics. The second section examines challenges that safety net programs will face when moving beyond the acute phase of COVID-19. The final section explores near-, middle-, and long-term policy options to mitigate federalism's harmful side effects.

Prevalence of Pre-existing Conditions Among Community Health Center Patients With COVID-19: Implications for the Patient Protection and Affordable Care Act.

BACKGROUND: Short- and long-term effects of COVID-19 will likely be designated pre-existing conditions. We describe the prevalence of pre-existing conditions among community health center patients overall and those with COVID-19 by race/ethnicity. MATERIALS AND METHODS: This cross-sectional study used electronic health record data from OCHIN, a network of 396 community health centers across 14 states. RESULTS: Among all patients with COVID-19, 33% did not have a pre-existing condition before the pandemic. Up to half of COVID-19-positive non-Hispanic Asians (51%), Hispanic (36%), and non-Hispanic black (28%) patients did not have a pre-existing condition before the pandemic. CONCLUSIONS: The future of the Patient Protection and Affordable Care Act is uncertain, and the long-term health effects of COVID-19 are largely unknown; therefore, ensuring people with pre-existing conditions can acquire health insurance is essential to achieving health equity.

Contraceptive Mandate, ACA Final Rules, And COVID-19.

The Supreme Court upheld broad exemptions to the Affordable Care Act contraceptive mandate; new ACA rules were finalized.

Risk Corridors, COVID-19, And The ACA.

The Supreme Court holds that the government owes insurers the full risk corridors payments due under the Affordable Care Act.