COVID-19 is not the first, nor the last, public health challenge the US political system has faced. Understanding drivers of governmental responses to public health emergencies is important for policy decision-making, planning, health and social outcomes, and advocacy. We use federal political disaster-aid debates to examine political factors related to variations in outcomes for Puerto Rico, Texas, and Florida after the 2017 hurricane season. Despite the comparable need and unprecedented mortality, Puerto Rico received delayed and substantially less aid. We find bipartisan participation in floor debates over aid to Texas and Florida, but primarily Democrat participation for Puerto Rican aid. Yet, deliberation and participation in the debates were strongly influenced by whether a state or district was at risk of natural disasters. Nearly one-third of all states did not participate in any aid debate. States' local disaster risk levels and political parties' attachments to different racial and ethnic groups may help explain Congressional public health disaster response failures. These lessons are of increasing importance in the face of growing collective action problems around the climate crisis and subsequent emergent threats from natural disasters.

Homelessness is a public health challenge for modern governments. Homelessness emerged as a formal policy problem for rich nations in the mid- to late 20th century as nations developed stable economies and democracies, including housing and job markets, and social welfare mechanisms to protect citizens from disenfranchisement. In early 21st-century Organisation for Economic Co-operation and Development (OECD) nations, homelessness arises most often among at-risk or vulnerable populations, such as historically marginalized groups and/or persons with constrained access to welfare state mechanisms, such as immigrants or refugees. Thus, homelessness in OECD nations is very different from informal housing or mass poverty in poor nations and/or non-democratic regimes. Homelessness affects individual and population health, requiring complex policy solutions across multiple domains of health, as well as intergovernmental coordination. Policy responses to homelessness vary across OECD nations in their approach and efficacy. There are four key factors influencing how OECD nations respond to homelessness: (a) the strength and inclusivity of the welfare state; (b) degrees of decentralization in homeless policy governance; (c) the strength, capacity, and inclusivity of the health and behavioral healthcare systems; and (d) the role of federated structures in health and welfare state policy. Overall, nations with weaker welfare states and health/behavioral healthcare systems face greater risks of homelessness. The inclusivity of these systems also shapes who may be eligible for protection or experience homelessness. Local governments, especially those in large metropolitan areas, are the frontline providers of homelessness services. Yet local governments are constrained at both ends: Policies designed, delivered, and funded at larger units of government—such as welfare state provisions—influence many of the determinants of homelessness, such as housing, and the resources available to subnational actors to combat homelessness. Local actors are also constrained by the degree of decentralization. Devolution of homelessness policy to smaller units of government or even solely to nongovernmental actors, through federated mechanisms or decentralization, may create barriers to locally tailored solutions by perpetuating disparities across jurisdictions and/or constraining authority and resources necessary to design or deliver homeless policy.

Context: Homeless policy advocates viewed Medicaid expansion as an opportunity to enhance health care access for this vulnerable population. We studied Medicaid expansion implementation to assess the extent to which broadening insurance eligibility affected the functioning of municipal homelessness programs targeting chronic homelessness in the context of two separate governance systems. Methods: We employed a comparative case study of San Francisco, California, and Shreveport, Louisiana, which were selected as exemplar cases from a national sample of cities across the United States. We conducted elite interviews with a range of local-level stakeholders and combined this data with primary-source documentation. Findings: Medicaid expansion did not substantially enhance the functioning of homelessness programs and policies because of Medicaid access challenges and governance conflicts. Administrative burden and funding limitations contributed to limited provider networks, inadequate service coverage, and lack of linkages between Medicaid enrollment and homelessness programming. Governance conflicts reinforced these functional challenges, with homelessness under the administration of local municipalities and nongovernmental organizations while states administer Medicaid. Conclusions: Improving access to health care services for persons experiencing homelessness cannot occur without intentional coordination between sectors and levels of government and thus necessitates the development of targeted policies and programs to overcome these challenges.

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

The professional autonomy of physicians often requires they take responsibility for life and death decisions, but they must also find ways to avoid bearing the full weight of such decisions. We conducted in‐person, semi‐structured interviews with neonatologists (n = 20) in four waves between 1978 and 2017 in a single Midwestern U.S. city. Using open coding analysis, we found over time that neonatologists described changes in their sense of professional autonomy and responsibility for decisions with life and death consequences. Through the early 1990s, as neonatology consolidated as a profession, physicians simultaneously enjoyed high levels of professional discretion and responsibility and were often constrained by bioethics and the law. By 2010s, high involvement of parents and collaboration with multiple subspecialties diffused the burden felt by individual practitioners, but neonatology’s professional autonomy was correlatively diminished. Decision‐making in the NICU over four decades reveal a complex relationship between the professional autonomy of neonatologist and the burden they bear, with some instances of ceding autonomy as a protective measure and other situations of unwelcomed erosion of professional autonomy that neonatologists see as complicating provision of care.

Politics, rather than disease characteristics, complicated the United States response to Ebola virus disease and Zika virus. We analyze how media and political elites shaped public opinion of the two outbreaks. We conducted a retrospective analysis of media coverage, Congressional floor speech, and public opinion polls to explain elite cueing and public perceptions of Ebola and Zika. We find evidence of elite cueing by Congress and the media on public opinion. Public opinion of both disease outbreaks initially followed partisan patterns. However, while Ebola public opinion remained partisan, ultimately, opinion emerged of a bipartisan nature for Zika, mirroring elite framing. Public health officials should be aware of how elite cueing shapes policy and prioritizes partisan strategies. Politics and public opinion can focus attention on or away from infectious disease; it can also undermine public health responses by biasing the public’s view of a diseases’ relative risk.

Background In 2015, Michigan implemented a rule requiring parents to attend an education session at a local health department (LHD) prior to waiving mandatory child vaccinations. This study utilizes Normalization Process Theory (NPT) to assess program implementation, identifying potential threats to fidelity and sustainability. Methods We conducted 32 semi-structured interviews with individuals involved in these education programs across 16 LHDs. Participating LHDs were selected from a stratified, representative sample. One interviewer conducted all interviews using a semi-structured interview guide; two authors coded and analyzed the interview transcripts according to the NPT framework (i.e, sense-making, engagement, collective action, and reflexive monitoring). Results There was a lack of consensus about who the stakeholders of this new rule and its resulting program were (sense-making). Perhaps as a result, most LHDs did not solicit advice from key stakeholder groups (i.e., schools, health care providers, community stakeholders) in their planning (engagement). While most interviewees identified providing education and information as the goal, some identified the more challenging goal of persuading vaccine hesitant parents to immunize their children. There was also some variation in perception of who held health educators accountable for meeting the goals of the waiver education program (collective action). Formal program evaluation by LHDs was rare, although some held informal staff debriefings. Additionally, sessions that went particularly well or poorly were top-of-mind (reflexive monitoring). Conclusions The immunization waiver education program may be at risk of not becoming fully embedded into routine LHD practice, potentially compromising its long-term effectiveness and sustainability. Managers at the local and state level should maintain oversight to ensure that the program is delivered with fidelity. As the program relies on sustaining inconvenience to encourage parents to immunize their children, any shortcuts taken will undermine its success.

Far from being an equalizer, as some have claimed, the COVID‐19 pandemic has exposed just how vulnerable many of our social, health, and political systems are in the face of major public health shocks. Rapid responses by health systems to meet increased demand for hospital beds while continuing to provide health services, largely via a shift to telehealth services, are critical adaptations. However, these actions are not sufficient to mitigate the impact of coronavirus for people from marginalized communities, particularly those with behavioral health conditions, who are experiencing disproportional health, economic, and social impacts from the evolving pandemic. Helping these communities weather this storm requires partnering with existing community‐based organizations and local governments to rapidly and flexibly meet the needs of vulnerable populations.

If disaster responses vary in their effectiveness across communities, health equity is affected. This paper aims to evaluate and describe variation in the federal disaster responses to 2017 Hurricanes Harvey, Irma and Maria, compared with the need and severity of storm damage through a retrospective analysis. Our analysis spans from landfall to 6 months after landfall for each hurricane. To examine differences in disaster responses across the hurricanes, we focus on measures of federal spending, federal resources distributed and direct and indirect storm-mortality counts. Federal spending estimates come from congressional appropriations and Federal Emergency Management Agency (FEMA) records. Resource estimates come from FEMA documents and news releases. Mortality counts come from National Oceanic and Atmospheric Administration (NOAA) reports, respective vital statistics offices and news articles. Damage estimates came from NOAA reports. In each case, we compare the responses and the severity at critical time points after the storm based on FEMA time logs. Our results show that the federal government responded on a larger scale and much more quickly across measures of federal money and staffing to Hurricanes Harvey and Irma in Texas and Florida, compared with Hurricane Maria in Puerto Rico. The variation in the responses was not commensurate with storm severity and need after landfall in the case of Puerto Rico compared with Texas and Florida. Assuming that disaster responses should be at least commensurate to the degree of storm severity and need of the population, the insufficient response received by Puerto Rico raises concern for growth in health disparities and increases in adverse health outcomes.

The election of Donald Trump has led to a dramatic shift in how states are using Section 1115 waivers in Medicaid and raises serious concerns for these programs, their populations, and public health. Waivers have been an important policy tool allowing states to modify, with federal approval, their Medicaid programs. Of the 36 states that have adopted the Medicaid expansion under The Patient Protection and Affordable Care Act (ACA; Pub L No. 111-148, 124 Stat. 855 [March 2010]), eight used a waiver. During the Obama administration, waivers were used largely by conservative state policymakers to alignMedicaid with their political ideology. These states focused on applying the concept of personal responsibility and free-market principles in the program, such as increasing cost-sharing, introducing health savings accounts, and incentivizing healthy behavior programs among the newly eligible.1 Other policies that that these states pursued in an effort to increase personal responsibility, such as work requirements, were rejected by the Obama administration

"The Affordable Care Act (ACA) expanded and improved health insurance coverage in two primary ways. First, the number of individuals receiving health insurance coverage expanded by increasing access to coverage through Medicaid expansion and providing subsidies to purchase private insurance on the health care exchanges. Second, the ACA upgraded the quality and scope of coverage by improving benefit design, including implementing the essential health benefits (EHBs). Essential health benefits are minimum insurance benefits encompassing 10 categories of care, which the ACA required all individual and small-group market plans as well as all plans sold on the health care exchanges, to cover. Mandating benefits for individual and small-group markets was a historic step, improving population health by providing access to crucial health care services for millions of Americans. Although some components of the ACA are popular with Republican policymakers, including coverage for preexisting conditions and Medicaid expansion, the EHBs' future is in doubt.

Housing is a critical social determinant of health. Housing policy not only affects health by improving housing quality, affordability, and insecurity; housing policy affects health upstream through the politics that shape housing policy design, implementation, and management. These politics, or governance strategies, determine the successes or failures of housing policy programs. This paper is an overview of challenges in housing policy governance in the United States. I examine the important relationship between housing and health, and emphasize why studying housing policy governance matters. I then present three cases of housing governance challenges in the United States, from each pathway by which housing affects health - housing quality, affordability, and insecurity. Each case corresponds to an arm of the TAPIC framework for evaluating governance, to assess mechanisms of housing governance in each case. While housing governance has come a long way over the past century, political decentralization and the expansion of the submerged state have increased the number of political actors and policy conflict in many areas. This creates inherent challenges for improving account- ability, transparency, and policy capacity. In many instances, too, reduced government accountability and transparency increases the risk of harm to the public and lessens governmental integrity.

If health policy truly seeks to improve population health and reduce health disparities, addressing homelessness must be a priority Homelessness is a public health problem. Nearly a decade after the great recession of 2008, homelessness rates are once again rising across the United States, with the number of persons experiencing homelessness surpassing the number of individuals suffering from opioid use disorders annually. Homelessness presents serious adverse consequences for physical and mental health, and ultimately worsens health disparities for already at-risk low-income and minority populations. While some state-level policies have been implemented to address homelessness, these services are often not designed to target chronic homelessness and subsequently fail in policy implementation by engendering barriers to local homeless policy solutions. In the face of this crisis, Ungoverned and Out of Sight seeks to understand the political processes influencing adoption of best-practice solutions to reduce chronic homelessness in US municipalities. Drawing on unique research from three exemplar municipal case studies in San Francisco, CA, Atlanta, GA, and Shreveport, LA, this volume explores conflicting policy solutions in the highly decentralized homeless policy space and provides recommendations to improve homeless governance systems and deliver policies that will successfully diminish chronic homelessness. Until issues of authority and fragmentation across competing or misaligned policy spaces are addressed through improved coordination and oversight, local and national policies intended to reduce homelessness may not succeed.

In this chapter, we analyze the health and social policies that emerged in the first six months of the pandemic, to combat COVID-19 in the US. These policies have a complicated record. The US has largely failed in their efforts to combat COVID-19 through public health policies. In the weeks after the pandemic declaration, the US appropriated trillions of dollars in an attempt to strengthen its social safety net. But, as will be shown, these efforts have been hampered by the policies themselves and the politics shaping them. We conclude by highlighting factors that combined to pattern the failures of the US response to COVID-19.

Policies and models concerning the novel coronavirus disease (COVID-19) that operate on the assumption that preparedness and response will occur under typical circumstances and not concurrent with other disasters—such as hurricanes or wildfires—may create perverse incentives to plan and prepare for only one disaster at a time. Planning and preparing for a single disaster is a problem because populations often experience mass migration in response to disasters, and planned disaster responses typically incorporate congregate shelter. Both long-distance migration and clustering in temporary shelters undermine social distancing as a mitigation strategy. Across the United States, current COVID-19 policies and models of disease trajectories do not take into account the risk of multiple, concurrent disasters, and therefore may incentivize broad under-preparedness to address SARS-CoV-2 transmission during extenuating circumstances as we move into hurricane, tornado, flood, and wildfire season. In the case of recent, unprecedented flooding in Midland, MI, emergency response measures utilized traditional flood evacuation protocols associated with a high risk of COVID-19 spread. This under-preparedness risked increased COVID-19 spread, morbidity, and mortality. Racial or ethnic minority groups, as a result of centuries of strategic political and economic oppression, are at highest risk of contracting and experiencing adverse health outcomes and mortality from COVID-19, and adverse consequences, morbidity, and mortality from natural disasters. In this persistent pandemic state, the United States cannot afford to promote siloed emergency planning and preparedness across various types of public health emergencies without further exacerbating health disparities. As such, we urge policymakers to establish disaster plans that explicitly incorporate the context of our current global pandemic.