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1.
Policy Points
- Persistent communication inequalities limit racial/ethnic minority access to life‐saving health information and make them more vulnerable to the effects of misinformation.
- Establishing data collection systems that detect and track acute gaps in the supply and/or access of racial/ethnic minority groups to credible health information is long overdue.
- Public investments and support for minority‐serving media and community outlets are needed to close persistent gaps in access to credible health information.
2.
ZACKARY BERGER VIVIAN ALTIERY DE JESUS SABRINA A. ASSOUMOU TRISHA GREENHALGH 《The Milbank quarterly》2021,99(2):519
Policy Points
Open in a separate windowThe natural history of long COVID appears to be gradual improvement over time in most cases, though recovery is typically measured in months. 6 , 8 Some patients require comprehensive assessment to exclude serious complications that might underlie their symptoms (notably, thrombo‐embolic disease of the lungs, heart, and brain), along with holistic clinical intervention and follow‐up. Patients without concerning symptoms should be supported but spared overinvestigation and overmedicalization. 6 , 16 , 17 Those who have survived admission to an intensive care unit and those with preexisting respiratory, cardiovascular, or cerebrovascular disease are likely to require more specialized and prolonged rehabilitation. 16 , 18 , 19 Given the paucity of evidence, it is currently unclear which of these issues related to long COVID are directly related to or caused by the disease itself and which are unrelated but may be made more difficult to treat owing to COVID‐19 and its after‐effects.Acute COVID‐19 is associated with significant racial disparities. 20 , 21 , 22 , 23 Black, Latinx, American Indian, Alaska Native, Asian, Native Hawaiian and Pacific Islander, and other non‐white racial groups in the United States are less likely to have access to testing; 24 , 25 more likely to be infected; 25 , 26 , 27 , 28 more likely to be hospitalized overall, 29 though less likely to be hospitalized for any given level of severity, 21 and more likely to have an adverse clinical outcome (including death). 21 , 27 , 30 , 31 In addition, these racial groups are overrepresented in high‐risk occupations, including those with a higher risk of mortality from COVID‐19 (e.g., health and care workers, hospital porters and cleaners, bus drivers, transport workers), 32 are less likely to have adequate health insurance, 33 and are less likely to receive compassionate end‐of‐life care. 34 They are also more likely to be severely affected economically with job losses or lack of access to welfare. 35 , 36 While they are also more likely to have comorbidities and poor prognostic features (e.g., obesity), 4 , 37 controlling for such factors reduces the differences in COVID‐19 mortality among ethnic groups and, in some cases, eradicates them altogether, 20 , 38 prompting calls to go beyond “biological” explanations. 3 , 39 Later we discuss structural explanations for racial disparities in the onset and outcome of acute COVID‐19, summarized schematically in Figure 1. 2 , 3 , 4 , 20 , 40 , 41 , 42 Open in a separate windowFigure 1Relationship Between Structural Inequalities and COVID‐19, Which Explains the “Confounders” in the High Mortality Rates for Some Ethnic GroupsAdapted from an original diagram by Bentley 2 under Creative Commons License.Whereas the association between race/ethnicity and health inequity in acute COVID‐19 is now well established, the association of inequities with long COVID is relatively unexplored. 4 , 22 , 43 To improve the care of vulnerable populations with long COVID, we need to (1) understand, acknowledge, and engage with the densely woven patterns of disadvantage that encumber those with postacute and chronic illness; 44 (2) strengthen existing services, especially in ambulatory primary care; (3) optimize data quality and use those data strategically for planning and monitoring; and (4) provide access to resources in acknowledgement of the multiple nested domains of inequity operating at global, national, community, and individual scales. We will consider these approaches in turn. 相似文献
- An estimated 700,000 people in the United States have “long COVID,” that is, symptoms of COVID‐19 persisting beyond three weeks.
- COVID‐19 and its long‐term sequelae are strongly influenced by social determinants such as poverty and by structural inequalities such as racism and discrimination.
- Primary care providers are in a unique position to provide and coordinate care for vulnerable patients with long COVID.
- Policy measures should include strengthening primary care, optimizing data quality, and addressing the multiple nested domains of inequity.
The Lived Experience Symptoms may be continuous or fluctuating
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Clinical Examination and Tests May identify signs of past infection, active inflammatory disease or systemic complications, including
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Comorbidities and Other Relevant Concerns Note: not all new symptoms in a patient after COVID‐19 are due to long COVID
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3.
GUENDALINA GRAFFIGNA LORENZO PALAMENGHI MARIAROSARIA SAVARESE GRETA CASTELLINI SERENA BARELLO 《The Milbank quarterly》2021,99(2):369
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.
4.
Policy Points
- In this paper we propose a middle‐ground policy for the distribution of an effective COVID‐19 vaccine, between a cosmopolitan approach that rejects entirely nation‐state priority and unbridled vaccine nationalism that disregards obligations to promote an equitable global allocation of an effective vaccine over time.
- Features of the COVAX partnership, a collaboration among the Global Alliance for Vaccines and Immunizations (GAVI), the Coalition for Epidemic Preparedness Innovations (CEPI), and the World Health Organization (WHO) to develop and distribute COVID‐19 vaccines make it an appropriate framework for a middle‐ground policy.
We are gravely concerned with the serious risks posed to all countries, particularly developing and least developed countries, and notably in Africa and small island states, where health systems and economies may be less able to cope with the challenge, as well as the particular risk faced by refugees and displaced persons. We consider that consolidating Africa''s health defense is a key for the resilience of global health. We will strengthen capacity building and technical assistance, especially to at‐risk communities. We stand ready to mobilize development and humanitarian financing. 1In the race to develop an effective vaccine, many experts have called for a more coordinated global approach, in which individual countries agree to abandon their national interest in securing vaccines for their own populations and hand over the responsibility to distribute the vaccine globally based on need. A group of bioethicists proposed what they term the “Fair Priority Model,” advocating vaccine distribution in three phases. 2 The first phase would be devoted to reducing premature deaths and irreversible direct and indirect health impacts; the second to reducing serious economic and social deprivations; and the third to reducing community transmission. They argue that all countries should go through the three phases “approximately simultaneously.” In this model, the distribution principles are based strictly on medical and economic criteria that identify the effects of the vaccine and wealthy countries would not receive the vaccine earlier just because they have the resources to buy it.Another influential approach, proposed by the World Health Organization (WHO), similarly envisages a distribution scheme in which the vaccines are distributed to countries based on the number of high‐risk groups in each country. A country should first obtain enough vaccine to cover frontline health care workers, covering 3% of the highest‐risk individuals first and then continue with other high‐risk groups such as the elderly and people with comorbidities, until 20% of each country''s population has been covered.Both the Fair Priority Model and the WHO proposal seem to disregard the relevance of national borders; that is, all countries should receive a supply of vaccines simultaneously in accordance with country‐independent criteria. Here we argue that both these approaches are untenable and that national governments have both a right and a duty to secure access to a COVID‐19 vaccine for their citizens first. Accordingly, we propose a middle‐ground policy perspective based on two premises: (1) a “cosmopolitan” approach that rejects entirely nation‐state priority is not only unrealistic but also fails to recognize that countries have a legitimate responsibility to give priority to their own citizens and residents; and (2) unbridled vaccine nationalism, without an adequately funded effort to ensure the equitable global allocation of an effective vaccine over time, is unethical and likely to be counterproductive.We present three interdependent arguments for our position. First, we believe that a prioritization framework should include a distribution scheme that can be implemented, rather than one that simply proposes general principles of distribution. Second, any viable prioritization scheme needs to start with nation‐states’ responsibility to secure the health of their populations. Third, appropriate weight needs to be given to national obligations of international assistance for low‐income countries to mobilize resources for health. We argue that the COVAX partnership provides a framework that approximates the right balance between national responsibilities for health and international commitments to global justice. 相似文献
5.
JON KINGSDALE 《The Milbank quarterly》2021,99(1):41-61
Policy Points
- Fixing the ACA requires real cost containment in addition to better subsidies.
- Private Medicare (Medicare Advantage) plans are uniquely empowered to control costs and deliver good care.
- Medicare Advantage plans should serve as the public option on the ACA Marketplace.
- Medicare Advantage plans can also be deployed to voluntarily raise minimum employer‐sponsored benefits and contain their costs.
6.
Policy Points
- The United States finds itself in the middle of an unprecedented combination of crises: a global pandemic, economic crisis, and unprecedented civic responses to structural racism.
- While public sector responses to these crises have faced much justified criticism, the commercial determinants of these crises have not been sufficiently examined.
- In this commentary we examine the nature of the contributions of such actors to the conditions that underpin these crises in the United States through their market and nonmarket activities.
- On the basis of this analysis, we make recommendations on the role of governance and civil society in relation to such commercial actors in a post‐COVID‐19 world.
7.
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.
8.
MARK PETTICREW NASON MAANI LUISA PETTIGREW HARRY RUTTER MAY CI VAN SCHALKWYK 《The Milbank quarterly》2020,98(4):1290-1328
Policy Points
- Nudges steer people toward certain options but also allow them to go their own way. “Dark nudges” aim to change consumer behavior against their best interests. “Sludge” uses cognitive biases to make behavior change more difficult.
- We have identified dark nudges and sludge in alcohol industry corporate social responsibility (CSR) materials. These undermine the information on alcohol harms that they disseminate, and may normalize or encourage alcohol consumption.
- Policymakers and practitioners should be aware of how dark nudges and sludge are used by the alcohol industry to promote misinformation about alcohol harms to the public.
9.
Policy Points
- This analysis finds that government obesity policies in England have largely been proposed in a way that does not readily lead to implementation; that governments rarely commission evaluations of previous government strategies or learn from policy failures; that governments have tended to adopt less interventionist policy approaches; and that policies largely make high demands on individual agency, meaning they rely on individuals to make behavior changes rather than shaping external influences and are thus less likely to be effective or equitable.
- These findings may help explain why after 30 years of proposed government obesity policies, obesity prevalence and health inequities still have not been successfully reduced.
- If policymakers address the issues identified in this analysis, population obesity could be tackled more successfully, which has added urgency given the COVID‐19 pandemic.
10.
Policy Points
- We compared the structure of health care systems and the financial effects of the COVID‐19 pandemic on health care providers in the United States, England, Germany, and Israel: systems incorporating both public and private insurers and providers.
- The negative financial effects on health care providers have been more severe in the United States than elsewhere, owing to the prevalence of activity‐based payment systems, limited direct governmental control over available provider capacity, and the structure of governmental financial relief.
- In a pandemic, activity‐based payment reverses the conventional financial positions of payers and providers and may prevent providers from prioritizing public health because of the desire to avoid revenue loss caused by declines in patient visits.
11.
FREDERICK J. ZIMMERMAN 《The Milbank quarterly》2021,99(1):9-23
Policy Points
- The historical mission of public health is to ensure the conditions in which people can be healthy, and yet the field of public health has been distracted from this mission by an excessive reliance on randomized‐control trials, a lack of formal theoretical models, and a fear of politics.
- The field of population health science has emerged to rigorously address all of these constraints. It deserves ongoing and formal institutional support.
12.
JI E. CHANG ALDEN YUANHONG LAI AVNI GUPTA ANN M. NGUYEN CAROLYN A. BERRY DONNA R. SHELLEY 《The Milbank quarterly》2021,99(2):340
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.
13.
GEORGE STOYE BEN ZARANKO MARTIN SHIPLEY MARTIN MCKEE ERIC J. BRUNNER 《The Milbank quarterly》2020,98(4):1134-1170
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.
14.
ARLINE T. GERONIMUS JAY A. PEARSON ERIN LINNENBRINGER ALEXA K. EISENBERG CARMEN STOKES LANDON D. HUGHES AMY J. SCHULZ 《The Milbank quarterly》2020,98(4):1171
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.
15.
MAY CI VAN SCHALKWYK NASON MAANI JONATHAN COHEN MARTIN MCKEE MARK PETTICREW 《The Milbank quarterly》2021,99(2):467
Policy Points
- Despite the pandemic''s ongoing devastating impacts, it also offers the opportunity and lessons for building a better, fairer, and sustainable world.
- Transformational change will require new ways of working, challenging powerful individuals and industries who worsened the crisis, will act to exploit it for personal gain, and will work to ensure that the future aligns with their interests.
- A flourishing world needs strong and equitable structures and systems, including strengthened democratic, research, and educational institutions, supported by ideas and discourses that are free of opaque and conflicted influence and that challenge the status quo and inequitable distribution of power.
16.
JONATHAN PURTLE RENNIE JOSHI FLICE LÊSCHERBAN ROSIE MAE HENSON ANA V. DIEZ ROUX 《The Milbank quarterly》2021,99(3):794
Policy Points
- Mayoral officials’ opinions about the existence and fairness of health disparities in their city are positively associated with the magnitude of income‐based life expectancy disparity in their city.
- Associations between mayoral officials’ opinions about health disparities in their city and the magnitude of life expectancy disparity in their city are not moderated by the social or fiscal ideology of mayoral officials or the ideology of their constituents.
- Highly visible and publicized information about mortality disparities, such as that related to COVID‐19 disparities, has potential to elevate elected officials’ perceptions of the severity of health disparities and influence their opinions about the issue.
17.
WALTER D. DAWSON NATHAN A. BOUCHER ROBYN STONE COURTNEY H. VAN HOUTVEN 《The Milbank quarterly》2021,99(2):565
Policy Points
- To address systemic problems amplified by COVID‐19, we need to restructure US long‐term services and supports (LTSS) as they relate to both the health care systems and public health systems. We present both near‐term and long‐term policy solutions.
- Seven near‐term policy recommendations include requiring the uniform public reporting of COVID‐19 cases in all LTSS settings; identifying and supporting unpaid caregivers; bolstering protections for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing barriers to telehealth in LTSS; and providing incentives to care for vulnerable populations.
- Long‐term reform should focus on comprehensive workforce development, comprehensive LTSS financing reform, and the creation of an age‐friendly public health system.
18.
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.
19.
JENNIFER KARAS MONTEZ 《The Milbank quarterly》2020,98(4):1033-1052
Policy Points
- Explanations for the troubling trend in US life expectancy since the 1980s should be grounded in the dynamic changes in policies and political landscapes. Efforts to reverse this trend and put US life expectancy on par with other high‐income countries must address those factors.
- Of prime importance are the shifts in the balance of policymaking power in the United States, the polarization of state policy contexts, and the forces behind those changes.
20.
Policy Points
- 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.
- 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.
- A failure to adequately address the underlying lack of infrastructure in developing countries threatens to further limit the success of the COVAX Facility.