Pre-Class Reading Reflection for Social Policies Class

Pre-Class Reading Reflection for Social Policies Class

by Maria Glymour -

Please post in the forum or email to Maria if you are not able to post. 

•Identify a policy you think may have important health implications.
•Describe why an evaluation of that policy is informative (would an evaluation of the policy be primarily of interest as a policy evaluation or primarily a test of hypothesized mediators, or both?  If mediators, which mediators?)
•Specify the outcomes and populations you think most responsive or least responsive to the policy.
•Propose a study design to evaluate the policy
–Describe biggest challenge to implementing and drawing inferences

Re: Pre-Class Reading Reflection for Social Policies Class

by Maria Garcia -
•Identify a policy you think may have important health implications.
The following policy regarding housing in San Francisco could and does have important health implications:
Section 415 of the San Francisco Planning Code, or the Inclusionary Affordable Housing Program, requires residential developments with 10 or more units to pay an Affordable Housing Fee.  Project sponsors may apply for an alternative to the fee in the form of providing 12% of their units on-site or 20% of their units off-site as affordable to low- to moderate-income households.
 
•Describe why an evaluation of that policy is informative (primarily about the policy, or primarily a test of hypothesized mediators?)
I think that it is important to study the effect of policies regarding housing in San Francisco.  I have noticed that as the housing situation in San Francisco gets more tenuous for low income individuals, more of my patients are coming in complaining of increased stressors, with a number of downstream direct and indirect effects. My patients are complaining of insomnia, concerns about their childrens health (increased asthma, allergies, etc) from illegal housing units, as well as depression and decreased ability to care for their own chronic conditions. It is hard to address those as a primary care provider when you feel that you are not addressing the root cause. Being able to evaluate the health effects of a policy would help to devise social policies that are more just, and that have the potential to improve health rather than to have detrimental effects on health.
 
•Specify the outcomes and populations you think most responsive or least responsive to the policy.
As the readings mentioned, it seems like many of the prior evaluations of policies have focused on mental health outcomes, but with a multitude of different scales, and many that have been used are unvalidated measures. I think that one potential outcome or measure could be mental health or depression, using a validated scale such as the CES-D.  Other outcomes that could be potentially affected by an affordable housing policy could be rates of diabetes or hypertension, rates of substance abuse, preterm deliveries, etc. There are many potential outcomes that one could study, but the difficulty would be in ascertaining and defining appropriate control groups.
 
•Propose a study design to evaluate the policy
One study could look at those individuals who receive affordable housing and compare to individuals who remain on the waitlist. This way you would follow wo cohorts of individuals who are theoretically similar in terms of their eligibility for affordable housing.  The study would require that individuals be followed for a very long time given that most of the outcomes of interest are long-term outcomes.
 
–Describe biggest challenge to implementing and drawing inferences
One of the biggest challenges if the number of possible confounders that could be at play.  It is hard to identify an appropriate control in a study and to allow for the time needed for long-term outcomes to occur. It is also very difficult, as the review paper pointed out, to accurately define the outcomes of interest with validated measures.

Re: Pre-Class Reading Reflection for Social Policies Class

by Maria Glymour -

The wait list idea is excellent and one of the most promising approaches to providing rigorous evidence on the health effects of a policy.  It's tough to randomize, but the reality is that we are so often under-resourced that many people who are eligible will not receive the policy benefit.  Thus, we can use random allocation to the wait list as a natural experiment to estimate effects of the policy.  The goal being that with rigorous evidence that a policy improves health of beneficiaries, we can make the case to ultimately increase resources.  This is generally challenging both because of data access/linkages and getting everyone on board with the idea.  

Re: Pre-Class Reading Reflection for Social Policies Class

by Bliss Temple -

•Identify a policy you think may have important health implications.

From the Medicare guidelines for DME coverage:

a manual wheelchair is covered if:

  • Criteria A, B, C, D, and E are met; and
  • Criterion F or G is met.

A)

The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.

   A mobility limitation is one that:

Prevents the patient from accomplishing an ADL entirely, or places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an ADL; or

Prevents the patient from completing an ADL within a reasonable time frame.

B)

The patient’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.

C)

The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.

D)

Use of a manual wheelchair will significantly improve the patient’s ability to participate in ADLs and the patient will use it on a regular basis in the home.

E)

The patient has not expressed an unwillingness to use the manual wheelchair that is provided in the home.

F)

The patient has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day.

Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.

G)

The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

If the manual wheelchair will be used inside the home and the coverage criteria are not met, it will be denied as not medically necessary.

If the manual wheelchair will only be used outside the home, it will be denied as not medically necessary.

 

Note the italics above (which are mine):  wheelchairs are only covered if they are needed in the home and able to be used in the home

•Describe why an evaluation of that policy is informative (primarily about the policy, or primarily a test of hypothesized mediators? 

This policy seems important to me because achieving good health and participating to the fullest extent in life requires more than just activities in the home, but the Medicare definition of need for a manual wheelchair (N.B. similar policies are in place for other types of mobility equipment, too) is confined to needs in the home as well as effectively requiring that the patient has a wheelchair-accessible home. This policy may effectively render homebound patients who could be independently mobile in the community with appropriate equipment and prevents them from being able to do many IADLs as well as participate in economic and social life.

•Specify the outcomes and populations you think most responsive or least responsive to the policy.

For those whose mobility needs in and outside the home are similar, and who have wheelchair accessible homes, this policy probably leads to provision of appropriate equipment.  However, for anyone whose needs are different in the home and in the community (for example, someone who is able to propel a manual wheelchair on short flat distances sufficiently for home use, does not have the strength to propel a manual wheelchair in the community, but could use a power wheelchair) Medicare will only provide equipment that effectively renders the patient homebound whereas other equipment could provide comprehensive independent mobility.  For anyone who does not have a wheelchair accessible home and cannot afford to move to one, but can somehow get around in the home (e.g. by confining themself to a limited area, or scooting around the floor on their buttocks) sufficiently for everyday tasks, Medicare will not provide the equipment that would make independent comprehensive community mobility possible and therefore again effectively renders patients unnecessarily homebound.

•Propose a study design to evaluate the policy 

I propose a pilot study that randomizes patients with mobility impairments to the currently covered mobility equipment vs. the mobility equipment determined most appropriate for comprehensive mobility in both home and community.  Outcomes examined could be health-related quality of life, employment, and degree of social engagement.

–Describe biggest challenge to implementing and drawing inferences

This policy came about after a political hoopla over concerns about Medicare DME fraud, and I think that although it may be harming many there is likely little political support for re-evaluating it.  It might be hard for this reason to get permission and funding. 

Re: Pre-Class Reading Reflection for Social Policies Class

by Maria Glymour -

This is a very interesting and compelling example.  Was there any real evidence about the fraud?  Are there decent estimates about how many people are affected?

This seems to partly go back to how we conceptualize health, and whether Instrumental Activities of daily living are considered core goals for health policies.

Re: Pre-Class Reading Reflection for Social Policies Class

by Dominika Seidman -
•Identify a policy you think may have important health implications.
The federal government requires a 30 day waiting period between a woman's signing a consent form for sterilization and the actual sterilization procedure in order for a hospital to receive Medicaid reimbursement. While this policy was designed to prevent forced/coercive sterilization of poor and minority women, it's unclear if it does so, and may have important health implications including unintended pregnancy. This law impacts only Medicaid patients: women with private insurance can decide on the day of their delivery that they would like a sterilization procedure, and the surgery will be done prior to discharge with routine reimbursement from the private insurer. For Medicaid patients, even if they sign the consent form 30 days before delivery, if they deliver in a different hospital/clinic than their primary provider's setting and forget to bring the consent form to the delivery, most facilities will refuse to do the procedure.
 
•Describe why an evaluation of that policy is informative (would an evaluation of the policy be primarily of interest as a policy evaluation or primarily a test of hypothesized mediators, or both?  If mediators, which mediators?)
I think this policy deserves primarily evaluation. We need to understand what the law is actually doing: is it protecting women from reproductive coercion? Is it functioning as a barrier for Medicaid patients to exercise their reproductive rights?
 
•Specify the outcomes and populations you think most responsive or least responsive to the policy.
This policy impacts female, reproductive aged Medicaid patients. Important outcomes to consider include the proportion of women who desire sterilization and have sterilization performed, proportion of women who desire sterilization but do not have sterilization performed due to logistical barriers imposed by the law, proportion of women who do not have sterilization performed at the time desired (usually delivery) but who present for an interval procedure after their papers are 30 days old, the proportion who do not have sterilization performed but who access a contraceptive method, proportion with tubal regret (regretting sterilzation), proprotion who report experiencing coercion, rates of unintended pregnancy, abortion, and short inter-pregnancy interval. I also think it would be interesting to look at what proportion of women understand the Medicaid consent form they are signing (the font is microscopic, the wording is painfully awkward...).
 
•Propose a study design to evaluate the policy
While there have been descriptive studies of unintended pregnancies after refused procedures and modeling studies to predict averted unintended pregnancies with legislative change, I think we need an RCT to get the law changed. I think you could randomize states to continue to require the 30 d waiting period and to treat the procedure like any other and use a regular surgical consent form. While it would be nice to be able to randomize on the hospital level, I think that would be confusing for implementation/training providers, and for the Medicaid reimbursement office. You'd then want to follow women for years (3-5?) to evaluate for repeat births and pregnancy outcomes. You could get a lot of this data from Medicaid, although finding the # of abortions and the % intended vs unintended pregnancies might be more challenging. You'd want to survey women in each state about their experiences of the sterilization consent process: did they feel coerced? Do they have regret? Did they feel informed during the consenting process? I think it might be interesting to do a substudy of women in both groups asking them at the time of sterilization what they had consented to, the permanence of sterlization, and their understanding risks/benefits/alternatives.
 
–Describe biggest challenge to implementing and drawing inferences
I think the biggest barrier would be training providers in states without the 30 d waiting period to not refuse patients who don't have their forms. These forms have been a part of obstetrical practice for decades; you learn as an intern that they are essential for obstetrical wards to stay in business. I also think that there could be differences in practice patterns/methods of counseling /obtaining informed consent that vary by state; hopefully randomization would take care of these differences, but they might be hard to measure. Finally, it might be hard to tell the difference in Medicaid data between women who were refused a sterilzation due to paper work and women who just changed their minds. Some of this info could be approximated from the subset of women who were surveyed, but it would challenging to extract that data specifically on all patients.

Re: Pre-Class Reading Reflection for Social Policies Class

by Maria Glymour -

Do we really need an RCT for this?  Would simply data on the % of women who follow through, accompanied by qualitative or simple quantitative interviews with women who did not as to their motivations and whether they felt the law protected them, be sufficient?  Or is the potential for coercion more subtle than could be picked up with such an approach?

Re: Pre-Class Reading Reflection for Social Policies Class

by Kristyn -

•Identify a policy you think may have important health implications.

I think Direct to Consumer marketing of prescription medicines has important health implications.

•Describe why an evaluation of that policy is informative (primarily about the policy, or primarily a test of hypothesized mediators?)

I think an evaluation of this policy would be informative - companies and proponents of the policy claim that it encourage people to seek medical advice from health professionals, inform patients about diseases/medical conditions and possible treatments, and may remove the stigma associated with certain diseases and medical conditions. However, only the US and New Zealand allow this practice.

•Specify the outcomes and populations you think most responsive or least responsive to the policy.

I think outcomes would be use of prescription drugs and mortality. I think populations that are most responsive will be health-conscious and higher class because they are most likely the group being bombarded with ads in print and media and have the means to access care for things that may be elective or optional (compared to life saving treatments).

•Propose a study design to evaluate the policy

There is already a natural comparison group to be studied in pretty much every other nation...so we could compare groups of people by age, diseases, and SES and see if those who ASKED for treatment due to DTC advertising are healthier/live longer than a comparable group not exposed to DTC

–Describe biggest challenge to implementing and drawing inferences

There are going to be a lot of confounders and a lot of backlash from lobbyists if we were ever going to ban DTC marketing of drugs. Obviously consumers should have access to information that helps them make informed decisions about their health, but ads for drugs still give me the creeps! If there was a real benefit in outcomes, etc, I think they should stay, however if a body of data demonstrated they were detrimental and lead to the over treatment of most patients, I think that ads for all medicines (even OTC) should be removed and replaced with more access to trained professionals like Drs and pharmacists like in the rest of the world.

Re: Pre-Class Reading Reflection for Social Policies Class

by Niharika Dixit -

•Identify a policy you think may have important health implications.

 

From my perspective as an oncologist housing is a big issues in cancer care. Section 8 Federal housing programs with vouchers or rent subsidy has important health implication. Based on informal data at least 10-20 % of cancer patient at SFGH may be homeless or unstably housed. When a person is diagnosed with cancer and cannot work due their treatment and symptoms burden, paying rent can be impossible and is usually the first thing to go.

 

 

•Describe why an evaluation of that policy is informative (primarily about the policy, or primarily a test of hypothesized mediators?)

 

Evaluation of this policy in my patient population can have far reaching implications for cancer care.

Patient with no housing/unstable housing are less likely to have primary health care.

They are less likely to be screened for cancer and more likely to present with advanced cancer.

They are less likely to receive cancer care (Not all providers are comfortable treating patient who are homeless, in fact majority will not offer treatments like chemotherapy).

They may be excluded from curative treatments if considered high risk for infection due to their housing. (One of my patients was turned down for transplant because of shared bathroom with other families and requirement to take public transport to the transplant center).

They may not be able to form community ties and social support which are associated with better outcomes.

Patients with unstable or no housing are more likely to experience psychosocial distress

They may have to be admitted to a center for end of life care rather than home hospice.

  

•Specify the outcomes and populations you think most responsive or least responsive to the policy.

The outcomes that will be most responsive in patients with diagnosis of cancer are

Receipt and non-receipt of timely cancer care.

Completion of planned treatment.

Psychosocial distress measures as assessed by NCCN ( National comprehensive cancer network) distress thermometer.

Overall survival.

 

The outcomes and populations that may be less responsive

Screening rates may still remain low as several other factors determine screening.

Cancer patient with mental health condition and substance abuse may have more challenges.

 

  

•Propose a study design to evaluate the policy

Study design: The study will have 2 parts, 

Observational cohort study and second part will be  a clinical trial with housing intervention.

The population would be cancer patients presenting to safety net hospitals in California.

To begin I would assess the proportion of patient with cancer who are homeless or unstably housed.

I will use a matched cohort with stable housing.

The outcome of interest will be number of patient who will receive treatment in curative and palliative care settings.

Secondary outcomes: Overall survival between the two groups, number of hospital admission and chemotherapy related side effects, psychosocial distress.

If there are significant differences, I would like to continue the study for a second cohort of home less cancer patients, intervention group will receive expedited housing versus routine housing for other group.

  

–Describe biggest challenge to implementing and drawing inferences

There may be several cofounders while housing is one issue. Other issue such as lower SES itself, education level/health literacy, insurance status  and type of cancer may play a role in patient outcomes.

While I believe cancer patients should always get priority for housing, there are other families with children and patients with non-cancer chronic diseases who are waiting for housing.

It takes sometimes the diagnosis of cancer alone to turn a stably housed person to homeless if he /she can no longer work and have a large share of cost. These patient may not be identified at the outset.

Undocumented immigrants may not qualify for these programs.

 

 

Re: Pre-Class Reading Reflection for Social Policies Class

by Maria Glymour -

Great example of the intersection of a social determinant and the medical care system - and an illustration of how simple social factors undermine the success of highly sophisticated medical systems.  The usual barrier to housing interventions is that they are expensive.  What is the comparison to the cost of cancer care?

Re: Pre-Class Reading Reflection for Social Policies Class

by Brian -
•Identify a policy you think may have important health implications.
The affordable care act includes the hospital readmissions reductions program (HRRP) to provide incentives to hospitals to reduce 30-day readmission rates (~20%). There is some concern that this policy would unfairly punish academic hospitals as well as safety-net hospitals because they treat sicker patients and may have more "non-preventable readmission." This has implications for widening disparities amongst stronger performing hospitals and underperforming hospitals financially. 
 
 
•Describe why an evaluation of that policy is informative (would an evaluation of the policy be primarily of interest as a policy evaluation or primarily a test of hypothesized mediators, or both?  If mediators, which mediators?)
 I think it would be primarily of interest as a policy intervention/evaluation. But i think it could also answer the question of why types of hospitalizations or readmissions are actually preventable. What are the mediators that impact readmission that if one could improve on, could reduce readmission rate.
 
•Specify the outcomes and populations you think most responsive or least responsive to the policy.
The outcome is specified to be for those hospitalizations considered to be preventable - heart failure, pneumonia, MI (compared to surgical procedures, planned readmission, oncology-chemotherapy admission). 
 
Populations that are least responsive to the policy include those complex patients with high specialty care needs, such as those served at UCSF/academic hospitals. 
 
Populations with low socioeconomic status, safety-net populations would also be least responsive to policy-- unclear why this is, but could posit that 1) less quality care at these hospitals; 2) populations have low rates of health literacy/understanding- so are not taking medication/treatment plan as directed--> readmitted; 3) lack of resources to assess in times of need/ stress. 
 
•Propose a study design to evaluate the policy
–Describe biggest challenge to implementing and drawing inferences
 
A couple ways come to mind for study design to evaluate policy. One could do a pre/post time-series analysis -- measure the readmission rates prior to initiating policy, then after policy is initiated to see if any effect on quality or outcome. Challenge to drawing inference is that other things are happening during this time period to improve the outcome that would need to be accounted for. 
 
Another way is the choose several test site/ hospitals to participate in the policy, and compare their performance versus those non-participators. The problem here is that those hospitals who are selected to participate in the program may be quite different from those who are non-participators in ways that would affect the difference in results. 

Re: Pre-Class Reading Reflection for Social Policies Class

by Juno -

Homework for Class on May 14, 2015

 

•Identify a policy you think may have important health implications.

 

Although there have been many gains made in the health and legal access of LGBTQ people around the U.S. many are surprised to know that in 29 states individuals can still be fired, refused housing or denied civic and social services solely on the basis of their sexual orientation and gender identity. These (absent) policies lead to grave disparities in housing/homelessness, education, and employment and subsequent financial security faced by many LGBTQ people. I am particularly compelled by discrimination in the employment setting as influencing health. Clearly, the legally authorized ability for employers to overlook eligible candidates or fire someone at will -- without cause – solely on the basis of their identity will have a significant ripple effect on individuals’ security and health.  There are many observations and experiments that have identified that actions by employers reflect the lack of accountability for non-discrimination in this area. For example, there was a study that was performed in Texas where job applicants wore either a “Texas and Proud” hat or a “Gay and Proud” hat and those with the “Gay and Proud” hat were less likely to receive call-backs. Similarly changing resumes to change references from “gay organization” to “progressive organization” increased interview offers by 40%.  Although these examples point to social enactment of discrimination that might not be directly affected by a law, having a law that would say prevent discrimination in hiring and firing practices would help establish ways and means to focus on, track, and pursue justice and compensation if appropriate. Legal pressure could influence social practices. Changing social and legal practices could have significant effects on the health and well-being of LGBTQ individuals who live in fear of being fired, made homeless, or unable to participate in civil society secondary to their sexual orientation or gender identity.

 

Though I would hope for a comprehensive non-discrimination bill that covered many topics a passage of The Employment Non-Discrimination Act (ENDA) or equivalent would provide basic protections against workplace discrimination on the basis of sexual orientation or gender identity. This bill was modeled on The Civil Rights Act of 1964 and the Americans with Disabilities Act. Though the bill passed the Senate in November 2013, the bill has yet to be introduced to Congress.

 

•Describe why an evaluation of that policy is informative (primarily about the policy, or primarily a test of hypothesized mediators?)

 

In many ways, employment non-discrimination seems self-evident to me. However, in light of the often co-existing socially mediated acts of discrimination, I think evaluating whether legal policy alone will be impactful would be important. For example, in the 29 states that have not yet passed state-level employment non-discrimination laws, may be more likely to have social environments that are less supportive of LGBT people. Appropriately states are one-by-one evaluating and some are implementing non-discrimination policies, but clearly many states still have not yet enacted important protections.  Therefore, I think this may be an opportune moment to evaluate how employment discrimination affects two axes: “quality of life” and “minority stress” among LGBTQ people both in states that have employment protections and those that don’t to consider how and if to encourage passage of ENDA (or something like it). I chose “quality of life” and “minority stress” because though a “soft outcome” I think the fear of discrimination and job instability is quite real and negatively affects many people. In this way I am seeing job discrimination as upstream cause of poor “quality of life” and increased “minority stress” that could lead to depression, substance use, or other poor health outcomes. These other outcomes, such as depression, substance use, or poor health could also be measured.

 

•Specify the outcomes and populations you think most responsive or least responsive to the policy.

 

For those who have professional careers, have high income levels, high personal/familial wealth, and have educational and racial/ethnic privilege -- I imagine these policies will be less directly impactful as there may be an autonomy buffer with respect to job acquisition and maintenance may be more within the individual’s control. Conversely, those individuals who face multiple oppressions i.e. they are a gender and sexual minority, are also a person of color, or have a co-existing disability, have low educational attainment, or low familial wealth may be more vulnerable to these policies. I would be interested to think about whether these policies would actually have a timely impact on income and wealth among LGBT people given that income and wealth may take longer to respond to policy changes than people’s feelings towards possible discrimination. Therefore, as I mentioned above, I would focus on quality of life measures and measurements of minority stress to see how those would shift with a changed legal climate.

 

•Propose a study design to evaluate the policy

In the prospective longitudinal cohort that I am helping to design – The PRIDE Study – we will be conducting annual health questionnaires for decades with LGBTQ people. As an entirely online survey we will also be tracking where people live and where they move to (using geolocation features and IP address mapping), as long as individuals stay within the United States. Coupled with questions about quality of life, minority stress, employment, discrimination, and tracking of major laws and subsequent evaluation for periodicity of effects (as determined by state legal policy) we will be able to observe the natural experiments across hopefully large populations of individuals as government policy changes. We will also be able to look in a cross-sectional manner at individuals reporting of employment discrimination in states that do and do not have employment non-discrimination policies.

 

The biggest challenge will be to understand how these policy changes actually affect individual and collective experience. It is my hope that we will have robust data prior to and after changes in legal policy but the challenge will be that other national and local policies will likely be changing at the same time as any employment non-discrimination policies. Therefore, identifying the direct effect of these policies on individuals and communities will be quite confounded by the “changing sociopolitical climate.” 

Re: Pre-Class Reading Reflection for Social Policies Class

by Elizabeth Rose Mayeda -

Paid family leave. Much of the discussion I see in the news is about how paid maternity leave influences women’s careers and earning potential (from those in favor of it) and the burden on businesses (from those against it). I haven’t seen as much in the news about the potential health effects of maternity leave, although it seems clear it could have health effects for the baby, the mother, and probably also to the co-parent. Framing paid family leave as a health issue might be a more compelling argument to some opponents of paid family leave. I am very far from an expert on paid family leave policies, but I think low income families would be the most influenced by paid family leave policies—these individuals are the least likely to have jobs that offer paid family leave.

Short-term health outcomes that I think would be responsive to paid leave after childbirth include:

  • Mental health of the mother and her partner
  • Breastfeeding
  • Infant growth and development outcomes
  • Attending recommended well-baby and well-mother health care visits after childbirth
  • Meeting recommended infant immunization schedule
  • Domestic violence
  • Obesity/weight change of mother after childbirth (this is the physical health outcome I can think of that is a measure of morbidity in mid-adulthood)

If new paid family leave policies were implemented at the state level, we could do a difference in difference analysis comparing states that have and have not adopt paid parental leave policies. Currently, several states (including California) have policies for partially paid leave for 4-6 weeks after childbirth. For some of the above health outcomes, such as infant immunization records, I think we could use existing state-level data to do a difference in difference analysis comparing states that implemented paid family leave policies and those that have not. Another idea might be to do a difference in difference analysis comparing health outcomes for employees of state governments or private companies that implemented paid family leave policies, and we might be able to use the data of the health insurance claims of employees to get more health information that only immunization rates. Most of the social policy studies we read examine a benefit that can people can be randomized to receive, and health outcomes can be measured in study participants. I don’t think it’s feasible to randomize people to receive paid family leave, which would make it very difficult to measure many of the health outcomes I outlined above).

Re: Pre-Class Reading Reflection for Social Policies Class

by Valy Fontil -

Excise or Value-added tax on sugar-weetened beverages (SSB)

Consumption of SSB is associatied with diabetes, obesity, hypertension and coronary heart disease. A tax policy that leads to reduced consumption could yield subtantial population health benefits including lowering the prevalence of childhood obesity and early-onset diabetes.

Health outcomes of interest would include childhood obesity, early-onset diabetes, cardiovascular disease. The magnitude of the health benefits are projected to be greatest for African Aericans, Mexican Americans, and low-income individuals because these populations have the highest consumption of SSB and highest rates of chronic diseases.

Investigators have used simulation modeling to project the effect of a proposed nation-wide and california tax on SSB. In 2014, the city of Berkeley levied a penny-per-ounce tax on sugar-sweetened drinks while San Francisco failed to pass a similar tax proposition. This potentially creates a natural experiment in which you can compare health outcomes in in Berkeley and San Francisco over the next 5 or 10 years.  Plausible outcomes of interest would be prevalence of chilhood obesity and incidence of hypertension or diabetes in teenagers.  The major challenge would be inherent demographic differences between Berkeley and San Francisco. However, other cities in the Bay Area and around the country have also failed to pass tax policies to reduce SSB consumption. One or more of these cities could serve as a more suitable comparison group.