Centralization vs. Decentralization in COVID-19 Responses: Lessons from China

Researchers have begun to examine whether centralized or decentralized (or federal) political systems have better handled the COVID-19 pandemic. In this paper, we probe beneath the surface of China’s political system to examine the balance between centralized and decentralized authority in China’s handling of the pandemic. We show that after the SARS epidemic of 2003, China adjusted the central–local balance of authority over systems to handle both the detection and early response phases of health emergencies. In an attempt to overcome problems revealed by SARS, it sought both to centralize early infectious disease reporting and to decentralize authority to respond to local health emergencies. But these adjustments in the central–local balance of authority after SARS did not change “normal times” authority relations and incentive structures in the political system. As a result, local leaders had both the authority and the incentive to prioritize tasks that determine their political advancement at the cost of containing the spread of COVID-19. China’s efforts to balance central and local authority shows just how difficult it is to get it right, especially in the early phase of a pandemic.

Authoritarian Regime Legitimacy and Health Care Provision: Survey Evidence from Contemporary China

Context: Over the last two decades a growing body of research has shown authoritarian regimes trying to increase their legitimacy by providing public goods. But there has so far been very little research on whether or not these regimes are successful. Methods: This article analyzes data from a 2012–2013 nationally representative survey in China to examine whether health care provision bolsters the communist regime’s legitimacy. Using multivariate ordinal logistic regression, we test whether having public health insurance and being satisfied with the health care system are associated with separate measures of the People’s Republic of China’s regime legitimacy: support for “our form of government” (which we call “system support”) and political trust. Findings: Having public health insurance is positively associated with trust in the Chinese central government. Health care system satisfaction is positively associated with system support and trust in local government. Conclusions: Health care provision may bolster the legitimacy of authoritarian regimes, with the clearest evidence showing that concrete benefits may translate into trust in the central government. Further research is needed to understand the relationship between trends in provision and legitimacy over time and in other types of authoritarian regime.

Potemkin Protections: Assessing Provider Directory Accuracy and Timely Access for Four Specialties in California

Context: Accurate provider directories and whether consumers can schedule timely appointments are crucial determinants of health access and outcomes. We assessed whether consumers can rely on provider directories to find in-network primary care providers, cardiologists, endocrinologists, and gastroenterologists for 2018 and 2019 for all managed care plans in California and whether they can access these providers in a timely manner. Method: We used large, random, and representative surveys of provider directories for all managed care plans in California for four specialties obtained from the California Department of Managed Health Care with a total of 657,012 observations (290,711 for 2018 and 475,524 for 2019). Findings: Surveys were able to verify provider directory entries for the four specialties for 59% to 76% of listings or 78% to 88% of providers reached. Moreover, we found that consumers were able to schedule urgent care appointments for 28% to 54% of listings or 44% to 72% of appropriately listed providers. For general care appointments, the percentages ranged from 35% to 64% of listed providers or 51% to 87% of appropriately listed providers. Differences across markets were generally small related to accuracy. Medi-Cal plans outperformed other markets with regards to timely access. Primary care consistently outperformed all other specialties. Timely access rates were higher for general appointments than for urgent care appointments. Conclusions: Despite the fact that California is one of the most active and well-resourced regulators in the nation, we found concerning results for consumers when it comes to locating in-network providers and gaining timely access. This raises questions about the regulatory regime as well as consumer access and health outcomes.

The Line Between Medicaid and Marketplace: Coverage Effects from Wisconsin’s Partial Expansion

Context: States have sought to experiment with the income eligibility threshold between Medicaid coverage and access to subsidized Marketplace plans in an effort to increase coverage for low-income adults while meeting other state priorities, particularly a balanced budget. In 2014, Wisconsin opted against adoption of an ACA Medicaid expansion, instead setting the Medicaid eligibility threshold at 100% of the poverty level—a state-funded partial expansion. Childless adults gained new eligibility, while parents and caregivers with incomes between 101–200% of poverty lost existing eligibility. Methods: We use Wisconsin’s all-payer claims database to assess health insurance gains, losses, and transitions among low-income adults affected by this partial expansion. Findings: We find that less than one third of adults who lost Medicaid eligibility definitely took up commercial coverage, and many returned to Medicaid. Among those newly Medicaid eligible, there was little evidence of crowd-out. Both groups experienced limited continuity of coverage. Overall, new Medicaid enrollment of childless adults was offset by coverage losses among parents and caregivers, rendering Wisconsin’s overall coverage gains similar to non-expansion states. Conclusions: Wisconsin’s experience demonstrates the difficulty in relying on the Marketplace to cover the near poor and suggests that full Medicaid expansion more effectively increases coverage.

Experiences of Health Insurance among American Indian Elders and their Health Care Providers

Context: American Indian Elders have a lower life expectancy than other aging populations in the United States, due to inequities in health and access to health care. To reduce such disparities, the 2010 Affordable Care Act included provisions to increase insurance enrollment among American Indians. While the Indian Health Service remains underfunded, increases in insured rates have had significant impacts among American Indians and their health care providers. Methods: From June 2016-March 2017, we conducted qualitative interviews with 96 American Indian Elders (age 55+) and 47 professionals (including health care providers, outreach workers, public-sector administrators, and tribal leaders) in two Southwestern states. Interviews focused on Elders’ experiences with health care and health insurance. Transcripts were analyzed iteratively using open and focused coding techniques. Findings: Although tribal health programs have benefitted from insurance payments, the complexities of selecting, qualifying for, and maintaining health insurance are often profoundly alienating and destabilizing for American Indian Elders and communities. Conclusions: Findings underscore the inadequacy of health-system reforms based on the expansion of private and individual insurance plans in ameliorating health disparities among American Indian Elders. Policymakers must not neglect their responsibility to directly fund health care for American Indians.

Mexican-Origin Women’s Construction and Navigation of Racialized Identities: Implications for Health Amidst Restrictive Immigrant Policies

This study examines how Mexican-origin women construct and navigate racialized identities in a post-industrial northern border community during a period of prolonged restrictive immigration and immigrant policies, and considers mechanisms by which responses to racialization may shape health. This grounded theory analysis involves interviews with 48 Mexican-origin women in Detroit, Michigan, who identified as being in the first, 1.5, or second immigrant generation. In response to institutions and institutional agents using racializing markers to assess their legal status and policing access to health-promoting resources, women engaged in a range of strategies to resist being constructed as an “other.” Women used the same racializing markers or symbols of (il)legality that had been used against them as a malleable set of resources to resist processes of racialization and form, preserve, and affirm their identities. These responses include constructing an authorized immigrant identity, engaging in immigration advocacy, and resisting stigmatizing labels. These strategies may have different implications for health over time. Findings indicate the importance of addressing policies that promulgate or exacerbate racialization of Mexican-origin communities and other communities who experience growth through migration. Such policies include creating pathways to legalization and access to resources that have been actively invoked in racialization processes such as state-issued driver’s licenses.

The Political Realignment of Health: How Partisan Power Shaped Infant Health in the U.S., 1915–2017

The U.S. two-party system was transformed in the 1960s, when the Democratic Party abandoned its Jim Crow protectionism to incorporate the policy agenda fostered by the Civil Rights Movement and the Republican Party redirected its platform toward socioeconomic and racial conservatism. We argue that the policy agendas that the parties promote through presidents and state legislatures codify a racially patterned access to resources and power detrimental to the health of all. To test the hypothesis that fluctuations in overall and race-specific infant mortality rates (IMR) shift between the parties in power before and after the Political Realignment, we apply panel data analysis methods to state-level data from the National Center for Health Statistics, 1915–2017. Net of trend, overall, and race-specific infant mortality rates were not statistically different between presidential parties before the Political Realignment. This pattern, however, changed after the Political Realignment, with Republican administrations consistently underperforming Democratic ones. Net of trend, non-Southern state legislatures controlled by Republicans underperform Democratic ones in overall and racial IMRs in both periods.

What Is a “Racial Health Disparity”? Five Analytic Traditions

What exactly is a “racial health disparity”? This article explores five lenses that have been used to answer that question. It contends that racial health disparities have been presented—by both academic researchers and those outside of it—as problems of five varieties: of biology, of behavior, of place, of stress, of policy. It also argues that a sixth tradition exploring class—and its connection to race, racism, and health—has been underdeveloped. I examine each of these conceptions of racial disparities in turn. Baked into each interpretive prism is a set of assumptions about the mechanisms that produce disparities: a story, in other words, about where racial health disparities come from. Discursive boundaries set the parameters for policy debate, determining what is and is not included in proposed solutions. How one sees a racial health disparity, then, determines the strategies a society advocates—or ignores—for their elimination. I end by briefly discussing problems in the larger research ecosystem that dictates how racial health disparities are studied.

State Policies, Racial Disparities, and Income Support: A Way to Address Infant Outcomes and the Persistent Black-White Gap?

Low-birthweight and preterm births vary by state, and black mothers typically face twice the risk that their white counterparts do. This gap reflects an accumulation of psychosocial and material exposures which include interpersonal racism, as well as differential experience with area-level deprivation like residential segregation, and other harmful exposures that we refer to as “institutional” or “structural” racism. We use logistic regression models and a data set that includes all births from 1994-2017, as well as five state policies from this period—Aid to Families with Dependent Children/Temporary Aid for Needy Families, Housing Assistance, Medicaid, Minimum Wage and Earned Income Tax Credit—to examine whether these state social policies, designed to provide a financial “safety net,” are associated with risk reduction of low birthweight and preterm birth to black and white mothers, and whether variations in state generosity attenuate the racial inequalities in birth outcomes. We also examine whether the relationship between state policies and racial inequalities in birth outcomes is moderated by the education level of the mother. We find that the EITC reduces the risk of low birthweight and preterm birth for black mothers. The impact is much less consistent for white mothers. For both black and white mothers, the benefits to birth outcomes are larger for mothers with less education.