US state laws on medical freedom and investigational stem cell procedures: a call to focus on state-based legislation

The premature marketing of investigational stem cell interventions (SCIs) is a growing market in the US. Several US states have passed legislation to permit and promote unproven and experimental SCIs for individuals with terminal or chronic diseases. These SCI medical freedom laws, which are largely based on right-to-try legislation, increase access to experimental SCIs with little to no oversight. They undermine federal regulatory authority and can compromise patient safety and informed decision-making. SCI medical freedom laws have gone largely unnoticed by scientific societies interested in the responsible translation of stem cell medicine. In this article, we analyze state SCI medical freedom laws and describe their detrimental impact on patients and society. We contend that scientific and medical societies are uniquely poised to advocate against state-based policy promoting unproven SCIs but recognize resource and other constraints to advocate for or against legislation in 50 states. We recommend societies establish coalitions and share resources to address state-based SCI medical freedom laws and other legislation surrounding unproven SCIs.

Caught Between a Well-Intentioned State and a Hostile Federal System: Local Implementation of Inclusive Immigrant Policies

Policy Points Inclusive state immigrant policies that expand rights and resources for immigrants may improve population health, but little is known about their local-level implementation. Local actors that have anti-immigrant attitudes can hinder the implementation of state policies, whereas the persistent influence of anti-immigrant federal policies reinforces barriers to accessing health and other resources granted by state policies. Local actors that serve immigrants and support state policy implementation lack the resources to counter anti-immigrant climates and federal policy threats.

CONTEXT

In the United States, inclusive state-level policies can advance immigrant health and health care access by extending noncitizens' access to public benefits, workplace rights, and protections from immigration enforcement. Although state policies carry promise as structural population health interventions, there has been little examination of their implementation at the local level. Local jurisdictions play multiple roles in state policy implementation and possess distinct immigration climates. Examining the local implementation of state immigrant policy can address challenges and opportunities to ensure the health benefits of inclusive policies are realized equitably across states' regions.

METHODS

To examine the local implementation of state immigrant policies, we selected a purposive sample of California counties with large immigrant populations and distinct social and political dynamics and conducted and analyzed in-depth interviews with 20 community-based organizations that provided health, safety net, and other services.

FINDINGS

We found that there were tensions between the inclusionary goals of state immigrant policies and local anti-immigrant climates and federal policy changes. First, there were tensions between state policy goals and resistance from local law enforcement agencies and policymakers (e.g., Board of Supervisors). Second, because of the ongoing threats from federal immigration policies, there was a mismatch between the services and resources provided by state policies and local community needs. Finally, organizations that served immigrants were responsible for contributing to policy implementation but lacked resources to meet community needs while countering local resistance and federal policy threats.

CONCLUSIONS

This study contributes knowledge regarding the challenges that emerge after state immigrant policies are enacted. The tensions among state immigrant policies, local immigration climates, and federal policy changes indicate that state immigrant policies are not implemented equally across state communities, resulting in challenges and limited benefits from policies for many immigrant communities.

Beliefs and Attitudes about Vermont's Buprenorphine Decriminalization Law among Clinicians Who Prescribe Buprenorphine

BACKGROUND

On June 1, 2021, Vermont repealed all criminal penalties for possessing 224 milligrams or less of buprenorphine. We examined the potential impact of decriminalization with a survey of Vermont clinicians who prescribed buprenorphine within the past year.

METHODS

All 638 Vermont clinicians with a waiver to prescribe buprenorphine were emailed the survey by Vermont Department of Health; 117 responded. We estimated the prevalence of the following four outcomes, for all responding clinicians and stratified by clinician demographics and practice characteristics: awareness of decriminalization, beliefs about the effects of decriminalization, support for decriminalization, and changes in practice resulting from decriminalization.

RESULTS

72 (62%) prescribers correctly stated that Vermont does not have criminal penalties for buprenorphine possession. 107 (91%) support decriminalization. 56 (48%) believe that, because buprenorphine is decriminalized, their patients are more likely to give, sell, or trade the buprenorphine that is prescribed to them to someone else. However, only 5 providers (4%) said they now prescribe to fewer patients.

CONCLUSION

The great majority of Vermont clinicians who prescribe buprenorphine support its decriminalization and have not changed their prescribing practices because of decriminalization.

Left Behind: Medicaid Immigrant Exclusions and Access to Maternal Health Care Across the Reproductive-Perinatal Continuum

Noncitizen immigrants are often excluded from accessing critical safety-net programs, such as Medicaid. Access to health care plays a central role in current policy debates on maternal health. Yet, immigrant exclusions are rarely considered in maternal health policy research. Through open-ended interviews with 31 policymakers, researchers, and program administrators, we examined state variations in approaches to providing care for pregnant, post, and intrapartum immigrant women. We found four themes: (a) a patchwork safety-net exists that provides some access to immigrants ineligible for Medicaid; (b) patchwork coverage leads to patchwork care, which can contribute to maternal health inequities; (c) immigrant Medicaid policy is assembled along a hierarchy of deservingness based on documentation status; (d) Trump-era public charge rules and political climate may have a substantial chilling effect on benefit uptake regardless of eligibility. We discuss implications for efforts to expand Medicaid postpartum and address the maternal health crisis.

Association Between Partisan Affiliation of State Governments and State Mortality Rates Before and During the COVID-19 Pandemic

Policy Points The increasing political polarization of states reached new heights during the COVID-19 pandemic, when response plans differed sharply across party lines. This study found that states with Republican governors and larger Republican majorities in legislatures experienced higher death rates during the COVID-19 pandemic-and in preceding years-but these associations often lost statistical significance after adjusting for the average income and health status of state populations and for the policy orientations of the states. Future research may help clarify whether the higher death rates in these states result from policy choices or have other explanations, such as the tendency of voters with lower incomes or poorer health to elect Republican candidates.

CONTEXT

Increasing polarization of states reached a high point during the COVID-19 pandemic, when the party affiliation of elected officials often predicted their policy response. The health consequences of these divisions are unclear. Prior studies compared mortality rates based on presidential voting patterns, but few considered the partisan orientation of state officials. This study examined whether the partisan orientation of governors or legislatures was associated with mortality outcomes during the COVID-19 pandemic.

METHODS

Data on deaths and the partisan orientation of governors and legislators were obtained from the Centers for Disease Control and Prevention and the National Conference of State Legislatures, respectively. Linear regression was used to measure the association between Republican representation (percentage of seats held) in legislatures and (1) age-adjusted, all-cause mortality rates (AAMRs) in 2015-2021 and (2) excess death rates during three phases of the COVID-19 pandemic, controlling for median household income, the prevalence of four risk factors (obesity, chronic obstructive pulmonary disease, heart attack, stroke), and state policy orientation. Associations between excess death rates and the governor's party were also examined.

FINDINGS

States with Republican governors or greater Republican representation in legislatures experienced higher AAMRs during 2015-2021, lower excess death rates during Phase 1 of the COVID-19 pandemic (weeks ending March 28, 2020, through June 13, 2020), and higher excess death rates in Phases 2 and 3 (weeks ending June 20, 2020, through April 30, 2022; p < 0.05). Most associations lost statistical significance after adjustment for control variables.

CONCLUSIONS

Mortality was higher in states with Republican governors and greater Republican legislative representation before and during much of the pandemic. Observed associations could be explained by the adverse effects of policy choices, reverse causality (e.g., popularity of Republican candidates in states with lower socioeconomic and health status), or unmeasured factors that predominate in states with Republican leaders.

State Higher Education Funding during COVID-19: Exploring State-Level Characteristics Influencing Financing Decisions

Building on research examining state financing for higher education, our qualitative comparative case study investigates state policymakers' decisions for funding public higher education during the COVID-19 crisis in California and Texas. These states were purposively selected based on the size of their postsecondary sector, state partisanship, and higher education funding responses during the pandemic. Moreover, these states represent two of the largest public postsecondary enrollments nationally and serve a racially and ethnically diverse student population. Guiding our study is the Hearn and Ness (2018) framework investigating the ecology of state higher education policymaking, which offers four contextual categories that influence state policy decisions: socioeconomic context, organizational and policy context, politicoinstitutional context, and external context. This framework suggests underlying factors influencing the state funding process, while also providing an opportunity to expand on this theory through the unique COVID-19 context. We used deductive and inductive techniques to analyze 28 interviews with a range of actors, including state elected officials, state government staff, and higher education officials. We also examined 69 documents (state budgets, news articles, and state executive orders) to triangulate and verify our interview data. Two areas served as key events that ultimately influenced higher education funding decisions in California and Texas: (1) the preference of certain higher education institutions and (2) the availability and application of federal dollars. Furthermore, the organizational and policy context and the politico-institutional context, as defined by the Hearn and Ness framework, provided additional state-level factors that resulted in distinct responses. This study offers practical and theoretical contributions to higher education policy and practice, including highlighting the decision-making and prioritization processes of state policymakers when facing an unprecedented pandemic and crisis, and discussing common and unique factors influencing higher education policymaking in two different state contexts.

Opioid use disorder treatment and the role of New Jersey Medicaid policy changes: perspectives of office-based buprenorphine providers

Background: In the US, seventy percent of drug-related deaths are attributed to opioids. In response to the ongoing opioid crisis, New Jersey's (NJ) Medicaid program implemented the MATrx model to increase treatment access for Medicaid participants with opioid use disorder (OUD). The model's goals include increasing the number of office-based treatment providers, enhancing Medicaid reimbursement for certain treatment services, and elimination of prior authorizations for OUD medications.Objectives: To explore office-based addiction treatment providers' experiences delivering care in the context of statewide policy changes and their perspectives on treatment access changes and remaining barriers.Methods: This qualitative study used purposive sampling to recruit office-based New Jersey medications for opioid use disorder (MOUD) providers . Twenty-two providers (11 females, 11 males) discussed treatment experiences since the policy changes in 2019, including evaluations of the current state of OUD care in New Jersey and perceived outcomes of the MATrx model policy changes.Results: Providers reported the MOUD climate in NJ improved as Medicaid implemented policies intended to reduce barriers to care and increase treatment access. Elimination of prior authorizations was noted as important, as it reduced provider burden and allowed greater focus on care delivery. However, barriers remained, including stigma, pharmacy supply issues, and difficulty obtaining injectable or non-generic medication formulations.Conclusion: NJ policies may have improved access to care for Medicaid beneficiaries by reducing barriers to care and supporting providers in prescribing MOUD. Yet, stigma and lack of psychosocial supports still need to be addressed to further improve access and care quality.

Economic Value of Initial Implementation Activities for Proposed Ban on Sales of Over-The-Counter Diet Pills and Muscle-Building Supplements to Minors

Introduction

Over-the-counter diet pills, weight-loss supplements, and muscle-building supplements often contain harmful ingredients and are associated with eating disorder diagnoses and other negative health outcomes. This study estimated the value of state initial implementation activities, for example, regulation development, to implement a ban on the sale of dangerous over-the-counter diet pills and muscle-building supplements to minors.

Methods

We enumerated minimum, best, and maximum values for 22 inputs among 11 activities state employees may undertake if the legislation were signed into law. For employment costs, we estimated staff hours on the basis of data from 10 key informants and obtained salary ranges from a state government website. Data were collected and analyzed between September 2021 and January 2022. We calculated 95% CIs using 10,000 Monte Carlo simulations that varied inputs simultaneously and probabilistically. We conducted two sensitivity analyses using all minimum and all maximum salaries.

Results

The estimated value of state start-up activities was $47,536 (95% CI=$36,831-$57,381). Inputs with the largest impact on this estimate corresponded to combinations of the highest salary and greatest hours per task.

Conclusions

The state's one-time opportunity cost to initiate this age-restriction policy would be minimal considering potential health gains. Sensitivity analyses did not change the conclusion, especially if the state produces subregulations linked to existing law rather than new regulations.

State Policies on Child Maltreatment and Racial Disproportionality

Over the past several decades researchers have documented disproportionality for Black families across multiple decision-making points within the child welfare system. Yet, few studies have examined how specific state policies may impact disproportionality across decision points. The racial disproportionality index (RDI) was calculated for Black children in each state and Washington DC (N = 51) based on the proportion of children who were received a referral to CPS, a substantiated investigation, or entered foster care. A series of bivariate analyses (one-way ANOVAs; independent sample t-tests) were used to explore the relationship between the RDI and these decision points. Further analyses were conducted between the RDI and state policies (e.g., child maltreatment definitions, mandated reporting, and alternative response). Our results suggest there is an overrepresentation of Black children in CPS across the three decision points. This overrepresentation continues with specific state policies such as a state using harsh punishment in their definition of child maltreatment. Recommendations are provided for policy and research, including a suggestion for further exploration of state policies and county-level disproportionality indexes.

Exploring the impact of the New York State repeal of nonmedical vaccination exemptions on student enrollment, absenteeism, and school workload: Perspectives from a survey of school administrators

In June 2019, New York State (NYS) adopted Senate Bill 2994A eliminating nonmedical vaccine exemptions from school entry laws. Since student noncompliance with the law required school exclusion, we sought to evaluate the law's effects on student enrollment and absenteeism, and school workloads related to its implementation. In November 2019, we sent an electronic survey to NYS (excluding New York City) schools. Due to the COVID-19 pandemic, outreach was curtailed in March 2020 with 525 (14%) of 3,759 eligible schools responding. To account for non-response, results were analyzed using inverse probability weighting. After weighting, 39% (95% CI: 34%, 44%) of schools reported enrollment changes and 31% (95% CI: 26%, 36%) of schools reported absenteeism related to the law. In addition, 95% (95% CI: 93%, 98%) of schools reported holding meetings and/or preparing correspondence about the law, spending a mean of 14 (95% CI: 11, 18) hours on these communication efforts. Schools in the highest pre-mandate nonmedical exemption tertile (vs. lowest) were more likely to report enrollment and absenteeism changes, and higher workloads. While our results should be interpreted with caution, changes in student enrollment, absenteeism, and school workloads may represent important considerations for policymakers planning similar legislation.

The Buffering Effect of State Eviction and Foreclosure Policies for Mental Health during the COVID-19 Pandemic in the United States

The COVID-19 pandemic spurred an economic downturn that may have eroded population mental health, especially for renters and homeowners who experienced financial hardship and were at risk of housing loss. Using household-level data from the Census Bureau's Household Pulse Survey (n = 805,223; August 2020-August 2021) and state-level data on eviction/foreclosure bans, we estimated linear probability models with two-way fixed effects to (1) examine links between COVID-related financial hardship and anxiety/depression and (2) assess whether state eviction/foreclosure bans buffered the detrimental mental health impacts of financial hardship. Findings show that individuals who reported difficulty paying for household expenses and keeping up with rent or mortgage had increased anxiety and depression risks but that state eviction/foreclosure bans weakened these associations. Our findings underscore the importance of state policies in protecting mental health and suggest that heterogeneity in state responses may have contributed to mental health inequities during the pandemic.

How Governor Directives Changed Health Workforce Flexibility in Response to the COVID-19 Pandemic

OBJECTIVES

In times of heightened population health needs, the health workforce must respond quickly and efficiently, especially at the state level. We examined state governors' executive orders related to 2 key health workforce flexibility issues, scope of practice (SOP) and licensing, in response to the COVID-19 pandemic.

METHODS

We conducted an in-depth document review of state governors' executive orders introduced in 2020 in all 50 states and the District of Columbia. We conducted a thematic content analysis of the executive order language using an inductive process and then categorized executive orders by profession (advanced practice registered nurses, physician assistants, and pharmacists) and degree of flexibility granted; for licensing, we indicated yes or no for easing or waiving cross-state regulatory barriers.

RESULTS

We identified executive orders in 36 states containing explicit directives addressing SOP or out-of-state licensing, with those in 20 states easing regulatory barriers pertaining to both workforce issues. Seventeen states issued executive orders expanding SOP for advanced practice nurses and physician assistants, most commonly by completely waiving physician practice agreements, while those in 9 states expanded pharmacist SOP. Executive orders in 31 states and the District of Columbia eased or waived out-of-state licensing regulatory barriers, usually for all health care professionals.

CONCLUSION

Governor directives issued through executive orders played an important role in expanding health workforce flexibility in the first year of the pandemic, especially in states with restrictive practice regulations prior to COVID-19. Future research should examine what effects these temporary flexibilities may have had on patient and practice outcomes or on permanent efforts to relax practice restrictions for health care professionals.

Provision of Social Care Services by US Hospitals

Policy Points Hospitals address population health needs and patients' social determinants of health by offering social care services. Tax-exempt hospitals are required to invest in community benefits, including social care services programs, though most community benefits spending is toward unreimbursed health care services. Tax-exempt hospitals offer about 36% more social care services than for-profit hospitals. Among tax-exempt hospitals, those that allocate more resources to community benefits spending offer more types of social care services, but those in states with minimum community benefits spending requirements offer fewer social care services. Policymakers may consider specifically incentivizing community benefits expenditures toward particular social care services, including linking tax exemptions to implementation, utilization, and outcome targets, to more directly help patients.

CONTEXT

Despite growing interest in identifying patients' social needs, little is known about hospitals' provision of services to address them. We identify social care services offered by US hospitals and determine whether hospital spending or state policies toward community benefits are associated with the provision of these services by tax-exempt hospitals.

METHODS

National secondary data about hospitals were collected from the American Hospital Association Annual Survey, with additional Internal Revenue Service (IRS) Form 990 data on community benefits spending from CommunityBenefitInsight.org and state-level community benefits policies from HilltopInstitute.org. Descriptive statistics for types of social care services and hospital characteristics were calculated, with bivariate chi-square and t-tests comparing for-profit and tax-exempt hospitals. Multivariable Poisson regression was used to estimate associations between hospital characteristics and types of services offered and among tax-exempt hospitals to estimate associations between social care services and community benefits spending and policies. Multivariable logistic regressions modeled associations between community benefits spending/policies and each type of social care services.

FINDINGS

Private US hospitals offered an average of 5.7 types of social care services in 2018. Tax-exempt hospitals offered about 36% more social care services than for-profit hospitals. Larger number of beds, health system affiliation, and having community partnerships are associated with more social care services, whereas rural hospitals and those managed under contract offered fewer social care services. Among tax-exempt hospitals, greater community benefits spending is associated with offering more total (incidence rate ratio [IRR] = 1.10, p < 0.01) and patient-focused social care services (IRR = 1.16, p < 0.01). Hospitals in states with minimum community benefits spending requirements offered significantly fewer social care services.

CONCLUSIONS

Although tax-exempt status and increased community benefits spending were associated with increased social care services provision, the observation that certain hospital characteristics and state minimum community benefits spending requirements were associated with fewer social care services suggests opportunities for policy reform to increase social care services implementation.

Abortion Policy in the United States: The New Legal Landscape and Its Threats to Health and Socioeconomic Well-Being

Policy Points The historic 2022 Supreme Court Dobbs v Jackson Women's Health Organization decision has created a new public policy landscape in the United States that will restrict access to legal and safe abortion for a significant proportion of the population. Policies restricting access to abortion bring with them significant threats and harms to health by delaying or denying essential evidence-based medical care and increasing the risks for adverse maternal and infant outcomes, including death. Restrictive abortion policies will increase the number of children born into and living in poverty, increase the number of families experiencing serious financial instability and hardship, increase racial inequities in socioeconomic security, and put significant additional pressure on under-resourced social welfare systems.

Political Economy of the COVID-19 Pandemic: How State Policies Shape County-Level Disparities in COVID-19 Deaths

The authors examine how two state-level coronavirus disease 2019 (COVID-19) policy indices (one capturing economic support and one capturing stringency measures such as stay-at-home orders) were associated with county-level COVID-19 mortality from April through December 2020 and whether the policies were more beneficial for certain counties. Using multilevel negative binominal regression models, the authors found that high scores on both policy indices were associated with lower county-level COVID-19 mortality. However, the policies appeared to be most beneficial for counties with fewer physicians and larger shares of older adults, low-educated residents, and Trump voters. They appeared to be less effective in counties with larger shares of non-Hispanic Black and Hispanic residents. These findings underscore the importance of examining how state and local factors jointly shape COVID-19 mortality and indicate that the unequal benefits of pandemic policies may have contributed to county-level disparities in COVID-19 mortality.

The Impact of the New York Nurse Practitioner Modernization Act on the Employment of Nurse Practitioners in Primary Care

Expanding scope of practice (SOP) for nurse practitioners (NPs) may increase NP employment in primary care practices which can help meet the growing demand in primary care. We examined the impact of enacting less restrictive NP practice restrictions-NP Modernization Act-in New York State (NYS) on the overall employment of primary care NPs and specifically in underserved areas. We used longitudinal data from the SK&A outpatient database (2012-2018) to identify primary care practices in NYS and in the comparison states (Pennsylvania [PA] and New Jersey [NJ]). Using a difference-in-differences design with an event study specification, we compared changes in (1) the presence and (2) total counts of NPs in primary care practices in NYS and neighboring comparison states (ie, PA and NJ) before and after the policy change. The NP Modernization Act was associated with a 1.3 percentage point lower probability of a practice employing at least one NP on average across each of the 3 post-periods (95% CI: -.024, -.002). NP Modernization Act was associated with 0.065 fewer NPs on average across the post-period (95% CI: -.119, -.011). Results were similar in underserved areas. NP employment in primary care practices in NYS was lower after the NP Modernization Act than would have been expected based counterfactual of comparison states. The negative relationship may be explained by gains in provider efficiency which leads to reduced NP hiring in primary care. More research is needed to understand the relationship between SOP regulations, NP supply, and access to care.

State Policies and Health Disparities between Transgender and Cisgender Adults: Considerations and Challenges Using Population-Based Survey Data

CONTEXT

The authors examined the association between state-level policy protections and self-rated health disparities between transgender and cisgender adults.

METHODS

They used data on transgender (n = 4,982) and cisgender (n = 1,168,859) adults from the 2014-2019 Behavioral Risk Factor Surveillance System. The authors estimated state-specific health disparities between transgender and cisgender adults, and they used multivariable logistic regression models to compare adjusted odds ratios between transgender and cisgender adults by state-level policy environments.

FINDINGS

Transgender adults were significantly more likely to report poor/fair health, frequent mental distress, and frequent poor physical health days compared to cisgender adults. Disparities between transgender and cisgender adults were found in states with strengthened protections and in states with limited protections. Compared to transgender adults in states with limited protections, transgender adults in states with strengthened protections were marginally less likely to report frequent mental distress.

CONCLUSIONS

Transgender adults in most states reported worse self-rated health than their cisgender peers. Much more research and robust data collection on gender identity are needed to study the associations between state policies and transgender health and to identify best practices for achieving health equity for transgender Americans.

Rapid Discontinuation of Chronic, High-Dose Opioid Treatment for Pain: Prevalence and Associated Factors

PURPOSE

To examine the prevalence of rapid discontinuation of chronic, high-dose opioid analgesic treatment, and identify associated patient, clinician, and community factors.

METHODS

Using 2017-2018 retail pharmacy claims data from IQVIA, we identified chronic, high-dose opioid analgesic treatment episodes discontinued during these years and determined the percent of episodes meeting criteria for rapid discontinuation. We used multivariable logistic regression to estimate the probability of rapid discontinuation, conditional on having a discontinued chronic, high-dose opioid treatment episode, as a function of patient, provider, and county characteristics.

RESULTS

We identified 810,120 new, chronic, high-dose opioid treatment episodes discontinued in 2017 or 2018, of which 72.0% (n=583,415) were rapidly discontinued. Rapid discontinuation was significantly more likely among Medicare (aOR 1.14, 95% CI 1.12 to 1.15) and Medicaid enrollees (aOR 1.03, 95% CI 1.02 to 1.05) compared to the commercially insured; in counties with higher fatal overdose rates (aOR 1.03, 95% CI 1.01 to 1.04) compared to counties with the lowest fatal overdose rates; and in counties with a higher percentage of non-white residents (aOR 1.21 for counties in the highest quartile relative to the lowest, 95% CI 1.19 to 1.24). Likelihood of rapid discontinuation also varied by prescriber specialty.

CONCLUSIONS

Most chronic, high-dose opioid treatment episodes that ended in 2017 or 2018 were discontinued more rapidly than recommended by clinical guidelines, raising concerns about adverse patient outcomes. Our findings highlight the need to understand what drives discontinuation and to inform safer opioid tapering and discontinuation practices.

Determining the Existence and Strength of Teen Dating Violence Policy: Testing a Comparative State Internal Determinants Model

Research demonstrates that Teen Dating Violence (TDV) programs impact TDV knowledge, attitudes, and behaviors, decreasing the odds of TDV victimization and perpetration. Studies indicate that students who do not complete a TDV intervention have significantly higher odds of physical and emotional TDV victimization and emotional TDV perpetration. This study uses multiple logistic regression and multiple linear regression to examine predictors of the presence and the strength of state legislation addressing TDV education and school policies. Results indicate some success in predicting the existence of TDV laws but less support for forecasting the strength of the policies passed. Dominant political party and state median income were found to be potentially important determinants of TDV state school policies. A state's political culture influenced the strength of states' TDV policies. Showing that policy existence and strength are related to different processes is important for advocates to understand. Future research should look at additional variables and explore legislative histories.

State-Level Sexism and Gender Disparities in Health Care Access and Quality in the United States

In this investigation, we examined the associations between state-level structural sexism-a multidimensional index of gender inequities across economic, political, and cultural domains of the gender system-and health care access and quality among women and men in the United States. We linked administrative data gauging state-level gender gaps in pay, employment, poverty, political representation, and policy protections to individual-level data on health care availability, affordability, and quality from the national Consumer Survey of Health Care Access (2014-2019; N = 24,250). Results show that higher state-level sexism is associated with greater inability to access needed health care and more barriers to affording care for women but not for men. Furthermore, contrary to our hypothesis, women residing in states with higher state-level sexism report better quality of care than women in states with lower levels of sexism. These findings implicate state-level sexism in perpetuating gender disparities in health care.

Supporting the Behavioral Health of Older Adults: Evaluating a Multi-Site, Multi-Actor, Multi-Agency Initiative

Policymakers often overlook people living with physical disabilities and older adults' behavioral health (BH) needs. Older adults experience alarmingly high rates of mental illness and substance use disorders, which often intersect with neurocognitive challenges. Emerging evidence suggests the SARS-COV-2 pandemic has exacerbated these disparities. BH needs amongst older adults and people living with physical disabilities have major implications for policy and service delivery. While a multitude of local interventions to support BH exist, few state-level programs focus on this population. In 2015, Oregon established the Behavioral Health Initiative for Older Adults and People with Physical Disabilities (referred to as the Initiative) with this specific purpose. A multi-year evaluation of this Initiative suggests several important improvements have occurred. Yet, barriers remain that hinder optimal service provision and enable siloed aging and BH services between agencies. The findings indicate ways the Initiative can leverage initial successes to further support this population.

Data on Evaluations as a Foundation for States Rethinking Competency to Stand Trial

Competency to stand trial policies and processes vary significantly across jurisdictions, and, increasingly, state policymakers are looking for ways to improve their efficiency, equity, and effectiveness. This commentary describes the importance of certain data, including the number of evaluations ordered, to inform state policymaking, drawing on the strategies highlighted in a recently released guide for policymakers, Just and Well: Rethinking How States Approach Competency to Stand Trial.

A Roadmap for Successful State Sepsis Regulations-Lessons From New York

Supplemental Digital Content is available in the text.

New York state implemented the first state-level sepsis regulations in 2013. These regulations were associated with improved mortality, leading other states to consider similar steps. Our objective was to provide insight into New York state’s sepsis policy making process, creating a roadmap for policymakers in other states considering similar regulations.

[PERSONS WITH DISABILITIES IN TERMS OF THE SPREAD OF THE NEW CORONAVIRUS INFECTION COVID-19]

One of the vulnerable categories of the population during a pandemic of coronavirus infection is the disabled, both from the point of view of the high risk of a severe course of the disease, and from the point of view of the possibility of significantly limiting everyday, professional and social activities. The article discusses the regulatory and organizational measures taken to ensure the rights of people with disabilities in Russia to prevent the spread of coronavirus infection. The epidemiological situation and features of the spread of coronavirus in long-term care facilities have been analyzed. The mortality rate from COVID-19 among residents of inpatient institutions in the EU countries ranged from 24 to 80%, in Russia the average mortality rate was 2.34 per 100 patients, in St. Petersburg from 1.4% to 2.2% of the number of people living in dependence on the type of institution. Using the example of one of the stationary social service institutions in St. Petersburg, it has been shown that the timely introduction of a set of organizational measures makes it possible to successfully manage the spread of coronavirus among residents and staff of long-term care institutions.

State Variation in TANF Expenditures: Implications for Social Work and Social Policy

The Temporary Assistance for Needy Families (TANF) program is a federal block grant to the states, with a required state contribution. Although often viewed as a cash assistance program with work requirements and services targeted at extremely low-income families with children, only about one-quarter of all state and federal TANF funds are now used for traditional cash aid. Uses of funds vary widely by state, and alternatives range from refundable tax credits to support of state child welfare systems. In this article, the author examines the relationship between state categorical TANF spending and key social, political, and economic characteristics using data from 2015 to 2017 and multilevel linear models. Racial and ethnic demographics of the cash assistance caseload are associated with differences in spending, with states with larger proportions of the caseload composed of people of color devoting a lower percentage of effort to traditional benefits and more to alternative cash transfers. Changes in unemployment rate within states are associated with greater spending on basic assistance and reduced spending on alternative transfers. These findings indicate that, although TANF cash benefits spending may be economically responsive within the program's overall flexible structure, spending patterns raise issues of equity for disadvantaged families.

Washington's liquor license system and alcohol-related adverse health outcomes

BACKGROUND AND AIMS

In June 2012, Washington state (USA) implemented Initiative 1183, privatizing liquor sales. As a result, off-premises outlets increased from 330 to over 1400 and trading hours lengthened. Increased availability of liquor may lead to increased consumption. This study examines the impact of Initiative 1183 on alcohol-related adverse health outcomes, measured by inpatient hospitalizations for alcohol-related disorders and accidental injuries. It further assesses heterogeneity by urbanicity, because outlets increased most in metropolitan-urban areas.

DESIGN

County-by-quarter difference-in-difference linear regression models, estimated statewide and within metropolitan/rural strata.

SETTING AND PARTICIPANTS

Data are from AHRQ Healthcare Cost and Utilization State Inpatient Database 2010-2014 and HHS Area Health Resource File 2010-2014. Changes in the rates of hospitalizations in the 2.5 years following Initiative 1183 in Washington (n = 39 counties) are compared with changes in Oregon (n = 36 counties).

MEASUREMENTS

County rates of hospitalizations per 1000 residents, including all records with any-listed ICD-9 Clinical Classification Software code denoting an alcohol-related disorder, and all records with any-listed external cause of injury code denoting an accidental injury.

FINDINGS

The increase in the rate of accidental injury hospitalizations in Washington's metropolitan-urban counties was on average 0.289 hospitalizations per 1000 county residents per quarter greater than the simultaneous increase observed in Oregon (P = 0.017). This result was robust to alternative specifications using a propensity score matched sample and synthetic control methods with data from other comparison states. The evidence did not suggest that Initiative 1183 was associated with differential changes in the rate of hospitalizations for alcohol-related disorders in metropolitan-urban (P = 0.941), non-metropolitan-urban (P = 0.162), or rural counties (P = 0.876).

CONCLUSIONS

Implementing Washington's Initiative 1183 (privatizing liquor sales) appears to have been associated with a significant increase in the rate of accidental injury hospitalizations in urban counties in that state but does not appear to be significantly associated with changes in the rate of hospitalizations specifically for alcohol-related disorders within 2.5 years.

COVID-19 Policy Differences across US States: Shutdowns, Reopening, and Mask Mandates

This work used event study to examine the impact of three policies (shutdowns, reopening, and mask mandates) on changes in the daily COVID-19 infection growth rate at the state level in the US (February through August 2020). The results show the importance of early intervention: shutdowns and mask mandates reduced the COVID-19 infection growth rate immediately after being imposed statewide. Over the longer term, mask mandates had a larger effect on flattening the curve than shutdowns. The increase in the daily infection growth rate pushed state governments to shut down, but reopening led to significant increases in new cases 21 days afterward. The results suggest a dynamic social distancing approach: a shutdown for a short period followed by reopening, combined with universal mask wearing. We also found that the COVID-19 growth rate increased in states with higher percentages of essential workers (during reopening) and higher percentages of minorities (during the mask mandate period). Health insurance access for low-income workers (via Medicaid expansion) helped to reduce COVID-19 cases in the reopening model. The implications for public health show the importance of access to health insurance and mask mandates to protect low-income essential workers, but minority groups still face a higher risk of infection during the pandemic.

Addressing Provider Shortages in Rural America: The Role of State Opt-Out Policy Adoptions in Promoting Hospital Anesthesia Provision

BACKGROUND

Shortages of anesthesia providers in rural areas have long resulted in access limitations in many US states. This situation prompted federal legislation designed to promote increased usage of certified registered nurse anesthetists (CRNAs) in hospitals. Starting in 2001, state governors were afforded the option to adopt "opt-out" provisions, giving facilities in their states flexibility in utilizing CRNAs; specifically, adopting the opt-out policy removes physician oversight requirements for Medicare billing purposes.

METHODS

We used mixed effects generalized linear models to identify predictors of CRNA service provision in hospitals from 2011-2015.

RESULTS

We found that being located in an opt-out state does not result in increased odds of CRNA service provision in US hospitals. Higher levels of deprivation in counties, being located in rural geographic areas, and being a teaching hospital all influenced CRNA service provision.

CONCLUSIONS

Given that we found no evidence that being in an opt-out state increases the odds of using CRNAs in hospitals, we contribute to the growing literature suggesting that states adopting the opt-out policy have not realized increased health care access or reduced health care costs. As a result of other contextual restrictions on hospitals' decision-making, simply adopting the opt-out policy has not been enough to address anesthesia provider shortages.

Putting The Pieces Together Again: American States and the End of the ACA's Shared Responsibility Payment

The Tax Cuts and Jobs Act (TCJA) eliminated the ACA's "shared responsibility payment," which penalized those who failed to comply with the requirement to purchase health insurance. In this article the authors explain efforts in several states to respond to this change by adopting individual health insurance mandates at the state level. Although there are good reasons to think that states may be reluctant to consider establishing their own mandates, New Jersey, the District of Columbia, and Vermont quickly joined Massachusetts in establishing such measures in 2018. In 2019 California and Rhode Island enacted state-level mandates. Four other states-Maryland, Connecticut, Hawaii, and Washington-formally considered mandates but have not enacted them. The authors compare the policy debates among these states and one other state, New York, which has not seen a legislative proposal for a mandate despite its strong support for the ACA. Their analysis explores the dynamics within the US federal system when a key component of a complex and politically salient national initiative is eliminated and states are left with many policy, political, and administrative questions of what to do next.

Modeling Financial Eligibility for Medicaid Long-term Services and Supports

Medicaid plays a significant role in financing long-term services and supports (LTSS) for low-income elderly (65+) in the United States. We modeled the impact of changing income, home equity, and asset limitations on Medicaid eligibility across states. We found that one in five elderly adults (10 million individuals) meet all three tests and would be financially eligible for Medicaid LTSS. Imposing additional restrictions on income allowances and eligibility thresholds had greatest impact on financial eligibility for Medicaid LTSS. Few states have opted to restrict financial eligibility and are instead looking for ways to keep people living independently in the community.

The Association of State Opioid Misuse Prevention Policies With Patient- and Provider-Related Outcomes: A Scoping Review

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.

[The problems of efficient functioning of hot lines in health care]

The article analyzes experience of interaction of public authorities of the subjects of the Russian Federation in area of health protection with civil society using hot-lines. The advantages and disadvantages of this type communication channel are established too. The justifications for implementation of principles of "open health care" are presented considering "hot-lines" as tool of interaction between the government and society (citizens and public organizations).

States With Medically Needy Pathways: Differences in Long-Term and Temporary Medicaid Entry for Low-Income Medicare Beneficiaries

Medically needy pathways may provide temporary catastrophic coverage for low-income Medicare beneficiaries who do not otherwise qualify for full Medicaid benefits. Between January 2009 and June 2010, states with medically needy pathways had a higher percentage of low-income beneficiaries join Medicaid than states without such programs (7.5% vs. 4.1%, p < .01). However, among new full Medicaid participants, living in a state with a medically needy pathway was associated with a 3.8 percentage point (adjusted 95% confidence interval [1.8, 5.8]) increase in the probability of switching to partial Medicaid and a 4.5 percentage point (adjusted 95% confidence interval [2.9, 6.2]) increase in the probability of exiting Medicaid within 12 months. The predicted risk of leaving Medicaid was greatest when new Medicaid participants used only hospital services, rather than nursing home services, in their first month of Medicaid benefits. Alternative strategies for protecting low-income Medicare beneficiaries' access to care could provide more stable coverage.

Inclusive state immigrant policies and health insurance among Latino, Asian/Pacific Islander, Black, and White noncitizens in the United States

Objectives: Policy-making related to immigrant populations is increasingly conducted at the state-level. State policy contexts may influence health insurance coverage by determining noncitizens' access to social and economic resources and shaping social environments. Using nationally representative data, we investigate the relationship between level of inclusion of state immigrant policies and health insurance coverage and its variation by citizenship and race/ethnicity. Methods: Data included a measure of level of inclusion of the state policy context from a scan of 10 policies enacted prior to 2014 and data for adults ages 18-64 from the 2014 American Community Survey. A fixed-effects logistic regression model tested the association between having health insurance and the interaction of level of inclusiveness, citizenship, and race/ethnicity, controlling for state- and individual-level characteristics. Results: Latino noncitizens experienced higher rates of being insured in states with higher levels of inclusion, while Asian/Pacific Islander noncitizens experienced lower levels. The level of inclusion was not associated with differences in insurance coverage among noncitizen Whites and Blacks. Conclusions: Contexts with more inclusive immigrant policies may have the most benefit for Latino noncitizens.

The Affordable Care Act Medicaid Expansions and Personal Finance

Using a novel data set from a major credit bureau, we examine the early effects of the Affordable Care Act Medicaid expansions on personal finance. We analyze less common events such as personal bankruptcy, and more common occurrences such as medical collection balances, and change in credit scores. We estimate triple-difference models that compare individual outcomes across counties that expanded Medicaid versus counties that did not, and across expansion counties that had more uninsured residents versus those with fewer. Results demonstrate financial improvements in states that expanded their Medicaid programs as measured by improved credit scores, reduced balances past due as a percent of total debt, reduced probability of a medical collection balance of $1,000 or more, reduced probability of having one or more recent medical bills go to collections, reduction in the probability of experiencing a new derogatory balance of any type, reduced probability of incurring a new derogatory balance equal to $1,000 or more, and a reduction in the probability of a new bankruptcy filing.

Radon in Schools: A Brief Review of State Laws and Regulations in the United States

Exposure to Radon, a colorless, naturally occurring radioactive gas, is one of leading causes of lung cancer, and may pose a significant long-term risk for school age children. We examined the regulations and statutes in each US state related to radon in schools to delineate key features of policies and discrepancies among states that may have public health implications. Search terms such as "radon", "school", "mitigation", "certification", "licensing", and "radon resistant new construction" were used to scan current statutes from each state legislature's website and regulations from official state government websites for relevant regulatory and statutory requirements concerning radon in schools. State regulations related to the testing, mitigation, and public dissemination of radon levels in schools are inconsistent and the lack of nationwide indoor radon policy for schools may result in unacceptably high radon exposure levels in some US schools. We highlight the features and discrepancies of state laws and regulations concerning radon in schools, and offer several constructive means to reduce risks associated with radon exposure in school children.

The Association between State Policy Environments and Self-Rated Health Disparities for Sexual Minorities in the United States

A large body of research has documented disparities in health and access to care for lesbian, gay, and bisexual (LGB) people in the United States. Less research has examined how the level of legal protection afforded to LGB people (the state policy environment) affects health disparities for sexual minorities. This study used data on 14,687 sexual minority adults and 490,071 heterosexual adults from the 2014⁻2016 Behavioral Risk Factor Surveillance System to document differences in health. Unadjusted state-specific prevalence estimates and multivariable logistic regression models were used to compare poor/fair self-rated health by gender, sexual minority status, and state policy environments (comprehensive versus limited protections for LGB people). We found disparities in self-rated health between sexual minority adults and heterosexual adults in most states. On average, sexual minority men in states with limited protections and sexual minority women in states with either comprehensive or limited protections were more likely to report poor/fair self-rated health compared to their heterosexual counterparts. This study adds new findings on the association between state policy environments and self-rated health for sexual minorities and suggests differences in this relationship by gender. The associations and impacts of state-specific policies affecting LGB populations may vary by gender, as well as other intersectional identities.

Incorporating Economic Policy Into A 'Health-In-All-Policies' Agenda

Recognizing the health effects of nonhealth policies, scholars and others seeking to improve Americans' health have advocated the implementation of a culture of health-which would call attention to and prioritize health as a key outcome of policy making across all levels of government and in the private sector. Adopting this "health-in-all-policies" lens, policy makers are paying increasing attention to health impacts as they debate policies in areas such as urban planning, housing, and transportation. Yet the health impacts of economic policies that shape the distribution of income and wealth are often overlooked. Pooling data from all fifty states for the period 1990-2010, we provide a broad portrait of how economic policies affect health. Overall, we found better health outcomes in states that enacted higher tax credits for the poor or higher minimum wage laws and in states without a right-to-work law that limits union power. Notably, these policies focus on increasing the incomes of low-income and working-class families, instead of on shaping the resources available to wealthier individuals. Incorporating these findings into a health-in-all-policies agenda will require leadership from the health sector, including a willingness to step into core and polarizing debates about redistribution.

Public and Opinion Leader Willingness to Fund Obesity-Focused Policies in Kansas

Obesity increases the risk for leading causes of death, including cardiovascular disease and some cancers. Midwestern and southern states have the highest obesity rates-in Kansas, one in every three adults is obese. We compared the willingness of Kansas adults and opinion leaders to pay more in taxes to fund obesity prevention policies. In 2014, we asked a representative sample of 2,203 Kansas adults (response rate 15.7%) and 912 opinion leaders (response rate 55%) drawn from elected office and other sectors, including business and health, whether they would pay an additional $50 in annual taxes to support five policies that improve access to healthy foods and opportunities for physical activity. We used adjusted Wald tests to compare public and opinion leaders' responses, and regression analysis to assess whether differences in respondents' gender, age, location (urban/rural), race/ethnicity, and political stance affected results. Adjusting for demographic differences, Kansas adults were more willing than opinion leaders to pay $50 in taxes for each of the five policy interventions. This study demonstrates a willingness among residents of a fiscally conservative state to pay increased taxes for policies that could reduce population obesity rates. Health professionals, including nurses, can use these findings to educate policy makers in Kansas and geopolitically similar states about widespread public support for obesity prevention policies. Public health and other nurses could also apply our methods to assess support for obesity prevention policies in their jurisdictions.

Loose regulation of medical marijuana programs associated with higher rates of adult marijuana use but not cannabis use disorder

BACKGROUND AND AIMS

Most US states have passed medical marijuana laws (MMLs), with great variation in program regulation impacting enrollment rates. We aimed to compare changes in rates of marijuana use, heavy use and cannabis use disorder across age groups while accounting for whether states enacted medicalized (highly regulated) or non-medical mml programs.

DESIGN

Difference-in-differences estimates with time-varying state-level MML coded by program type (medicalized versus non-medical). Multi-level linear regression models adjusted for state-level random effects and covariates as well as historical trends in use.

SETTING

Nation-wide cross-sectional survey data from the US National Survey of Drug Use and Health (NSDUH) restricted use data portal aggregated at the state level.

PARTICIPANTS

Participants comprised 2004-13 NSDUH respondents (n ~ 67 500/year); age groups 12-17, 18-25 and 26+ years. States had implemented eight medicalized and 15 non-medical MML programs.

MEASUREMENTS

Primary outcome measures included (1) active (past-month) marijuana use; (2) heavy use (> 300 days/year); and (3) cannabis use disorder diagnosis, based on DSM-IV criteria. Covariates included program type, age group and state-level characteristics throughout the study period.

FINDINGS

Adults 26+ years of age living in states with non-medical MML programs increased past-month marijuana use 1.46% (from 4.13 to 6.59%, P = 0.01), skewing towards greater heavy marijuana by 2.36% (from 14.94 to 17.30, P = 0.09) after MMLs were enacted. However, no associated increase in the prevalence of cannabis use disorder was found during the study period. Our findings do not show increases in prevalence of marijuana use among adults in states with medicalized MML programs. Additionally, there were no increases in adolescent or young adult marijuana outcomes following MML passage, irrespective of program type.

CONCLUSIONS

Non-medical marijuana laws enacted in US states are associated with increased marijuana use, but only among adults aged 26+ years. Researchers and policymakers should consider program regulation and subgroup characteristics (i.e. demographics) when assessing for population level outcomes. Researchers and policymakers should consider program regulation and subgroup characteristics (i.e. demographics) when assessing for population level outcomes.

Intervention to Prevent Falls: Community-Based Clinics

PURPOSE

The purpose of this study was to document results of State funded fall prevention clinics on rates of self-reported falls and fall-related use of health services.

METHODS

Older adults participated in community-based fall prevention clinics providing individual assessments, interventions, and referrals to collaborating community providers. A pre-post design compares self-reported 6-month fall history and fall-related use of health care before and after clinic attendance.

RESULTS

Participants ( N = 751) were predominantly female (82%) averaging 81 years of age reporting vision (75%) and mobility (57%) difficulties. Assessments revealed polypharmacy (54%), moderate- to high-risk mobility issues (39%), and postural hypotension (10%). Self-reported preclinic fall rates were 256/751(34%) and postclinic rates were 81/751 (10.8%), ( p = .0001). Reported use of fall-related health services, including hospitalization, was also significantly lower after intervention.

IMPLICATIONS

Evidence-based assessments, risk-reducing recommendations, and referrals that include convenient exercise opportunities may reduce falls and utilization of health care services. Estimates regarding health care spending and policy are presented.

Does the Regulatory Environment Affect Nurse Practitioners' Patterns of Practice or Quality of Care in Health Centers?

OBJECTIVE

To examine the impact of state-granted nurse practitioner (NP) independence on patient-level quality, service utilization, and referrals.

DATA SOURCES/STUDY SETTING

The National Ambulatory Medical Care Survey's community health center (HC) subsample (2006-2011). Primary analyses included approximately 6,500 patient visits to 350 NPs in 220 HCs.

STUDY DESIGN

Propensity score matching and multivariate regression analysis were used to estimate the impact of state-granted NP independence on each outcome, separately. Estimates were adjusted for sampling weights and NAMCS's complex design.

DATA COLLECTION/EXTRACTION METHODS

Every "NP-patient visit unit" was isolated using practitioner and patient visit codes and, using geographic identifiers, assigned to its state-year and that state-year's level of NP independence based on scope of practice policies. Nine outcomes were specified using ICD-9 codes, standardized drug classification codes, and NAMCS survey items.

PRINCIPAL FINDINGS

After matching, no statistically significant differences in quality were detected by states' independence status, although NP visits in states with prescriptive independence received more educational services (aIRR 1.66; 95 percent CI 1.09-2.53; p = .02) and medications (aIRR 1.26; 95 percent CI 1.04-1.53; p = .02), and NP visits in states with practice independence had a higher odds of receiving physician referrals (AOR 1.88; 95 percent CI 1.10-3.22; p = .02) than those in restricted states.

CONCLUSIONS

Findings do not support a quality-scope of practice relationship.

The Effects of State-Mandated Abstinence-Based Sex Education on Teen Health Outcomes

In 2011, the USA had the second highest teen birth rate of any developed nation, according to the World Bank, . In an effort to lower teen pregnancy rates, several states have enacted policies requiring abstinence-based sex education. In this study, we utilize a difference-in-differences research design to analyze the causal effects of state-level sex education policies from 2000-2011 on various teen sexual health outcomes. We find that state-level abstinence education mandates have no effect on teen birth rates or abortion rates, although we find that state-level policies may affect teen sexually transmitted disease rates in some states. Copyright © 2016 John Wiley & Sons, Ltd.

The Role of Aging and Disability Resource Centers in Serving Adults Aging with Intellectual Disabilities and Their Families: Findings from Seven States

For the first time, adults with intellectual and developmental disabilities (I/DD) are living to experience old age. The purpose of this project was to assess the activities of aging and disability resource centers (ADRCs) as they seek to serve older adults with intellectual disabilities and their family caregivers. Data come from 21 in-depth qualitative interviews with ADRC staff in seven states. Results of this qualitative analysis indicate that ADRCs are not focusing explicitly on adults aging with I/DD and their family caregivers, but meeting the needs of this population is a future goal of ADRCs. Challenges related to accessing and providing information and referral services for adults aging with I/DD were described and highlight existing unmet needs of this population. Supporting adults who simultaneously require aging and disability services requires true coordination of aging and disability service systems.

Capacity and readiness for quality improvement among home and community-based service providers

The objective of this study was to explore home and community-based service (HCBS) providers' perspectives of organizational readiness for quality improvement (QI). Data were obtained from a survey of participants (N = 56) in a state-sponsored HCBS QI initiative. Quality improvement challenges included lack of time and resources, staff apprehension or resistance, resistance from consumers and families, and project sustainability. Support from leadership was viewed as an important factor in participating organizations' decision to engage in QI. Internal resources available to support QI varied widely between participating organizations, with differences observed between smaller and larger agencies, as well as between provider types and populations served.

Understanding the Lives and Challenges of Women in Poverty after TANF

Welfare Reform has caused a dramatic change in the lives and health of single mothers living in poverty. This qualitative study explored the health and socioeconomic lives of 22 community-dwelling women in poverty in the years after they were terminated from the current work-based welfare program intended to move women from welfare to work and independence. The instruments were a semistructured interview guide, the HANES General Well-Being Schedule, and a demographic data form. Data were analyzed using multistage narrative analysis and descriptive statistics. These primary source data showed participants had multiple barriers that precede or follow poverty. Their voices of how they survive are a rich source of data to assist providers and policy makers in devising evidence-based solutions for reducing poverty in America.

Medical Marijuana Laws Reduce Prescription Medication Use In Medicare Part D

Legalization of medical marijuana has been one of the most controversial areas of state policy change over the past twenty years. However, little is known about whether medical marijuana is being used clinically to any significant degree. Using data on all prescriptions filled by Medicare Part D enrollees from 2010 to 2013, we found that the use of prescription drugs for which marijuana could serve as a clinical alternative fell significantly, once a medical marijuana law was implemented. National overall reductions in Medicare program and enrollee spending when states implemented medical marijuana laws were estimated to be $165.2 million per year in 2013. The availability of medical marijuana has a significant effect on prescribing patterns and spending in Medicare Part D.

The Impact of State AIDS Drug Assistance Policies on Clinical and Economic Outcomes of People With HIV

We investigated the effect of changes to state AIDS Drug Assistance Programs (ADAP) policies, which govern access to antiretroviral therapy (ART), on clinical and economic outcomes among low-income people living with HIV/AIDS. Retrospective analyses of ART access were conducted on state ADAP policies, using data from ADAP Monitoring Reports and Kaiser Family Foundation from 2006 to 2010. We found stricter eligibility requirements reduce the number of HIV-positive individuals with ART access through ADAP, and decreased ART use increases mortality by 2.67 quality-adjusted life years (QALYs) per beneficiary. If the ADAP income eligibility cutoff were decreased by 50 percentage points in each state, 4,626 individuals would lose ART access nationwide. Based on a $22,143 cost/QALY, this policy would save $274 million in health care expenditures (2012 dollars), but result in 12,352 QALYs lost, valued at $1.2 billion. Therefore, states should exercise caution in restricting programs that increase ART access for low-income people living with HIV/AIDS.