Community engagement in the prevention and control of COVID-19: Insights from Vietnam

Introduction

Community engagement (CE) is an effective public health strategy for improving health outcomes. There is limited published knowledge about effective approaches to CE in ensuring effective responses to COVID-19 throughout lockdowns, travel restrictions and social distancing. In this paper, we contribute to bridging this gap by highlighting experience of CE in Vietnam, specifically focusing on migrant workers in Vietnam.

Methods

A cross-sectional qualitative study design was used with qualitative data collection was carried out during August-October 2020. Two districts were purposefully selected from two large industrial zones. Data was collected using in-depth interviews (n = 36) with individuals and households, migrants and owners of dormitories, industrial zone factory representatives, community representatives and health authorities. Data was analyzed using thematic analysis approach. The study received ethics approval from the Hanoi University Institutional Review Board.

Results

The government’s response to COVID-19 was spearheaded by the multi-sectoral National Steering Committee for the Prevention and Control of COVID-19, chaired by the Vice Prime Minister and comprised different members from 23 ministries. This structure was replicated throughout the province and local levels and all public and private organizations. Different activities were carried out by local communities, following four key principles of infection control: early detection, isolation, quarantine and hospitalization. We found three key determinants of engagement of migrant workers with COVID-19 prevention and control: availability of resources, appropriate capacity strengthening, transparent and continuous communication and a sense of trust in government legitimacy.

Discussion and conclusion

Our results support the current literature on CE in infection control which highlights the importance of context and suggests that future CE should consider five key components: multi-sectoral collaboration with a whole-of-community approach to strengthen governance structures with context-specific partnerships; mobilization of resources and decentralization of decision making to encourage self-reliance and building of local capacity; capacity building through training and supervision to local institutions; transparent and clear communication of health risks and sensitization of local communities to improve compliance and foster trust in the government measures; and understanding the urgent needs ensuring of social security and engaging all parts of the community, specifically the vulnerable groups.

Levels of Employment and Community Engagement among Low-Income Adults: Implications for Medicaid Work Requirements

CONTEXT

Twenty states are pursuing community engagement requirements ("work requirements") in Medicaid, though legal challenges are ongoing. While most nondisabled low-income individuals work, it is less clear how many engage in the required number of hours of qualifying community engagement activities and what heterogeneity may exist by race/ethnicity, age, and gender. The authors' objective was to estimate current levels of employment and other community engagement activities among potential Medicaid beneficiaries.

METHODS

The authors analyzed the US Census Bureau's national time-use survey data for the years 2015 through 2018. Their main sample consisted of nondisabled adults between 19 and 64 years with family incomes less than 138% of the federal poverty level (N = 2,551).

FINDINGS

Nationally, low-income adults who might become subject to Medicaid work requirements already spent an average of 30 hours per week on community engagement activities. However, 22% of the low-income population-particularly women, older adults, and those with less education-would not currently satisfy a 20-hour-per-week requirement.

CONCLUSIONS

Although the majority of potential Medicaid beneficiaries already meet community engagement requirements or are exempt, 22% would not currently satisfy a 20-hour-per-week requirement and therefore could be at risk for losing coverage.

Public Approval of Exception From Informed Consent in Emergency Clinical Trials: A Systematic Review of Community Consultation Surveys

IMPORTANCE

The US Food and Drug Administration (FDA) created the exception from informed consent (EFIC) pathway in 1996 to allow some emergency trials to enroll patients without informed consent. To protect individual autonomy and preserve public trust, the FDA requires that EFIC trial investigators consult with community members before a trial may begin.

OBJECTIVES

To analyze data from surveys conducted as part of community consultation ahead of EFIC trials and assess levels of public approval.

DATA SOURCES

All trials granted an EFIC must submit documentation of compliance with EFIC regulations to a publicly available docket at the FDA. Submissions between November 1, 1996, and October 23, 2017, were reviewed.

STUDY SELECTION

Trials with survey data were included.

DATA EXTRACTION AND SYNTHESIS

Data were extracted between January 2018 and June 2018 and were analyzed between June 2018 and August 2018. The quality and validity of data were assessed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A random-effects metaregression was used to assess the association of demographic characteristics with EFIC approval.

MAIN OUTCOMES AND MEASURES

The primary study outcome was EFIC approval.

RESULTS

The FDA docket contained 15 958 pages of material with survey data for 42 448 individuals submitted by 27 trials. Public approval of EFIC varied by question type, with more people willing to approve initiation of EFIC trials in their community (86.5%) than personal enrollment (73.0%), enrollment of a family member (68.6%), or the principle of enrollment without consent (58.4%) (P < .001 for all comparisons). In the United States, African American individuals made up 29.3% of those enrolled in EFIC trials that reported data on race (5064 of 17 302) but only 16.7% of those surveyed as part of community consultation. In the United States and Canada, men made up 42.9% of the surveyed population but 65.6% of those eventually enrolled in EFIC trials (29 961 of 45 694). Groups surveyed with higher proportions of African American and male respondents had lower rates of EFIC approval.

CONCLUSIONS AND RELEVANCE

Public approval of EFIC trials varied by question type and by the respondents' reported race and sex. The demographic characteristics of those surveyed did not match the demographic characteristics of EFIC enrollees. The FDA could strengthen community consultation by standardizing survey instruments and reporting, requiring broader inclusion of African American and male respondents, clarifying the function of surveys in the development and modification of trial protocols, and building more public consensus around the acceptable use of EFIC.

How Has the Presence of Zimbabwe's Victim-Friendly Court and Relevant Child Protection Policy and Legal Frameworks Affected the Management of Intrafamilial Child Sexual Abuse in Zimbabwe? The Case of Marondera District

The study intended to assess, based on the perceptions of Victim-Friendly Court (VFC) professionals in Marondera District in Zimbabwe, how the presence of the VFC and relevant child protection policy and legal frameworks has affected the management of Intrafamilial Child Sexual Abuse (ICSA) in Zimbabwe. Sem-istructured questionnaires were administered to 25 professionals from 13 VFC agencies in Marondera, while one-on-one semi-structured interviews were conducted with 15 key informants who included five ICSA survivors and their respective five caregivers as well as five key community child protection committee members. All 40 participants were selected using purposive sampling. Data were analyzed manually using thematic analysis, descriptive analysis, and document analysis. The study showed that the VFC manages ICSA through prevention, protection, treatment, and support interventions, and that its mandate is guided by key child protection policy and legal frameworks, particularly the National Action Plan for Orphaned and Vulnerable Children and the Children's Act (Chapter 5:06). The presence of these mechanisms is perceived to have resulted in increased awareness of ICSA, realization of effective results, increased reporting of ICSA, and enhanced coordination among VFC agencies. However, the same frameworks are perceived to be fraught with gaps and inconsistencies, too prescriptive, incoherent with some key aspects of the National Constitution and international child rights standards, and poorly resourced for effective implementation. All this has negatively affected the management of ICSA. Therefore, the Government of Zimbabwe should consistently review these systems to make them responsive to the ever-evolving factors associated with ICSA. Also, alignment with the National Constitution, full domestication of global child rights instruments, and routine collection of better statistics for evidence-based policy- and decision-making, and for better monitoring of progress and evaluation of outcomes, are necessary for positive results. Non-governmental stakeholders too should chip in with human, technical, and financial resources to enhance effective management of the social problem.

Meaningful participation for children in the Dutch child protection system: A critical analysis of relevant provisions in policy documents

Policymakers are increasingly focusing on the participation of children in the child protection system (CPS). However, research shows that actual practice still needs to be improved. Embedding children's participation in legislation and policy documents is one important prerequisite for achieving meaningful participation in child protection practice. In this study, the participation of children in the Dutch CPS under the new Youth Act 2015 is critically analyzed. National legislation and policy documents were studied using a model of "meaningful participation" based on article 12 of the UNCRC. Results show that the idea of children's participation is deeply embedded in the current Dutch CPS. However, Dutch policy documents do not fully cover the three dimensions of what is considered to be meaningful participation for children: informing, hearing, and involving. Furthermore, children's participation differs among the organizations included in the child protection chain. A clear overall policy concerning the participation of children in the Dutch CPS is lacking. The conclusions of this critical analysis of policy documents and the framework of meaningful participation presented may provide a basis for the embedding of meaningful participation for children in child protection systems of other countries.

Untangling outcomes of de jure and de facto community-based management of natural resources

We systematically reviewed the literature on the tragedy of the commons and common-property resources. We segregated studies by legal management regimes (de jure regimes) and management that develops in practice (de facto regimes) to understand how the structure of regime formation affects the outcome of community management on sustainability of resource use. De facto regimes, developed within the community, are more likely to have positive impacts on the resource. However, de facto regimes are fragile and not resilient in the face of increased population pressure and unregulated markets, and de facto management regimes are less successful where physical exclusion of external agents from resources is more difficult. Yet, formalization or imposition of de jure management regimes can have complicated impacts on sustainability. The imposition of de jure regimes usually has a negative outcome when existing de facto regimes operate at larger scales than the imposed de jure regime. In contrast, de jure regimes have largely positive impacts when the de facto regimes operate at scales smaller than the overlying de jure regimes. Formalization may also be counterproductive because of elite capture and the resulting de facto privatization (that allows elites to effectively exclude others) or de facto open access (where the disenfranchised may resort to theft and elites cannot effectively exclude them). This underscores that although the global movement to formalize community-management regimes may address some forms of inequity and may produce better outcomes, it does not ensure resource sustainability and may lead to greater marginalization of users. Comparison of governance systems that differentiate between initiatives that legitimize existing de facto regimes and systems that create new de facto regimes, investigations of new top-down de jure regimes, and studies that further examine different approaches to changing de jure regimes to de facto regimes are avenues for further inquiry.

Population Engagement and Consultation at the Local Level: Thailand Experience

The World Health Organization handbook on Strategizing National Health in the 21st Century has emphasized the importance of the process of population consultation on needs and expectations. According to Thailand National Health Act 2007, three innovative social tools for participatory healthy public policy process were proposed, i.e., health assembly, health impact assessment and health system statute (charter). In practice, population consultation process is required in the process of the tools implementation. Therefore, this paper aims to illustrate how local health statute implementation supports population participation and consultation at the local level. The first local health statute owned by Cha-lae sub-district in Songkla Province had been introduced in 2009. So far, there are above 500 sub-districts or "Tambon" having their own health system statutes. Tambon Administrative Organization (TAO), health and non-health sectors, community leaders and civil society seemed to be key actors or a mechanism for the local health statute. This demonstrated three crucial elements or sectors for policy development, i.e., policy maker, evidence support and society. Contents of the local health statute are wide ranged, including social determinants, risks and diseases, life style, health services, health fund, to mental and social health in regard to the local problem and context. Therefore, it needs the process of discussion and consultation to seek their common interest and expectation. Local health statute in Thailand is an example of engagement and consultation of the population for health policy. This confirmed the process of population consultation on their needs and expectation that can be implemented both at national and local levels. This is also the strategy to improve the accountability of policy makers for health impacts at all levels of policy making. The challenges of local health statute include the mechanism to maintain and ensure the engagement and ownership for sustainable implementation. Lastly, the local government's continued commitment toward providing funding support through the implementation process and the self-assessment framework of implementation is needed.

Data inconsistencies from states with unconventional oil and gas activity

The quality and availability of unconventional oil and gas (O&G) data in the United States have never been compared methodically state-to-state. By conducting such an assessment, this study seeks to better understand private and publicly sourced data variability and to identify data availability gaps. We developed an exploratory data-grading tool - Data Accessibility and Usability Index (DAUI) - to guide the review of O&G data quality. Between July and October 2013, we requested, collected, and assessed 5 categories of unconventional O&G data (wells drilled, violations, production, waste, and Class II disposal wells) from 10 states with active drilling activity. We based our assessment on eight data quality parameters (accessibility, usability, point location, completeness, metadata, agency responsiveness, accuracy, and cost). Using the DAUI, two authors graded the 10 states and then averaged their scores. The average score received across all states, data categories, and parameters was 67.1 out of 100, largely insufficient for proper data transparency. By state, Pennsylvania received the highest average ( = 93.5) and ranked first in all but one data category. The lowest scoring state was Texas ( = 44) largely due to its policy of charging for certain data. This article discusses the various reasons for scores received, as well as methodological limitations of the assessment metrics. We argue that the significant variability of unconventional O&G data-and its availability to the public-is a barrier to regulatory and industry transparency. The lack of transparency also impacts public education and broader participation in industry governance. This study supports the need to develop a set of data best management practices (BMPs) for state regulatory agencies and the O&G industry, and suggests potential BMPs for this purpose.

Deliberative democracy and cancer screening consent: a randomised control trial of the effect of a community jury on men's knowledge about and intentions to participate in PSA screening

OBJECTIVE

Prostate-specific antigen (PSA) screening is controversial. A community jury allows presentation of complex information and may clarify how participants view screening after being well-informed. We examined whether participating in a community jury had an effect on men's knowledge about and their intention to participate in PSA screening.

DESIGN

Random allocation to either a 2-day community jury or a control group, with preassessment, postassessment and 3-month follow-up assessment.

SETTING

Participants from the Gold Coast (Australia) recruited via radio, newspaper and community meetings.

PARTICIPANTS

Twenty-six men aged 50-70 years with no previous diagnosis of prostate cancer.

INTERVENTION

The control group (n=14) received factsheets on PSA screening. Community jury participants (n=12) received the same factsheets and further information about screening for prostate cancer. In addition, three experts presented information on PSA screening: a neutral scientific advisor provided background information, one expert emphasised the potential benefits of screening and another expert emphasised the potential harms. Participants discussed information, asked questions to the experts and deliberated on personal and policy decisions.

MAIN OUTCOME AND MEASURES

Our primary outcome was change in individual intention to have a PSA screening test. We also assessed knowledge about screening for prostate cancer.

RESULTS

Analyses were conducted using intention-to-treat. Immediately after the jury, the community jury group had less intention-to-screen for prostate cancer than men in the control group (effect size=-0.6 SD, p=0.05). This was sustained at 3-month follow-up. Community jury men also correctly identified PSA test accuracy and considered themselves more informed (effect size=1.2 SD, p<0.001).

CONCLUSIONS

Evidence-informed deliberation of the harms and benefits of PSA screening effects men's individual choice to be screened for prostate cancer. Community juries may be a valid method for eliciting target group input to policy decisions.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry (ACTRN12612001079831).

The federal medical loss ratio rule: implications for consumers in year 2

For the past two years, the Affordable Care Act has required health insurers to pay out a minimum percentage of premiums in the form of medical claims or quality improvement expenses--known as a medical loss ratio (MLR). Insurers with MLRs below the minimum must rebate the difference to consumers. This issue brief finds that total rebates for 2012 were $513 million, half the amount paid out in 2011, indicating greater compliance with the MLR rule. Spending on quality improvement remained low, at less than 1 percent of premiums. Insurers continued to reduce their administrative and sales costs, such as brokers' fees, without increasing profit margins, for a total reduction in overhead of $1.4 billion. In the first two years under this regulation, total consumer benefits related to the medical loss ratio--both rebates and reduced overhead--amounted to more than $3 billion.

A systems-based conceptual framework for assessing the determinants of a social license to operate in the mining industry

The concept of a "social license to operate" (SLO) was coined in the 1990s and gained popularity as one way in which "social" considerations can be addressed in mineral development decision making. The need for a SLO implies that developers require the widespread approval of local community members for their projects to avoid exposure to potentially costly conflict and business risks. Only a limited amount of scholarship exists on the topic, and there is a need for research that specifically addresses the complex and changeable nature of SLO outcomes. In response to these challenges, this paper advances a novel, systems-based conceptual framework for assessing SLO determinants and outcomes in the mining industry. Two strands of systems theory are specifically highlighted-complex adaptive systems and resilience-and the roles of context, key system variables, emergence, change, uncertainty, feedbacks, cross-scale effects, multiple stable states, thresholds, and resilience are discussed. The framework was developed from the results of a multi-year research project which involved international mining case study investigations, a comprehensive literature review, and interviews conducted with mining stakeholders and observers. The framework can help guide SLO analysis and management efforts, by encouraging users to account for important contextual and complexity-oriented elements present in SLO settings. We apply the framework to a case study in Alaska, USA before discussing its merits and challenges. We also illustrate knowledge gaps associated with applications of complex adaptive systems and resilience theories to the study of SLO dynamics, and discuss opportunities for future research.

Comparative effectiveness research as choice architecture: the behavioral law and economics solution to the health care cost crisis

With the Patient Protection and Affordable Care Act ("ACA") set to dramatically increase access to medical care, the problem of rising costs will move center stage in health law and policy discussions. "Consumer directed health care" proposals, which provide patients with financial incentives to equate marginal costs and benefits of care at the point of treatment, demand more decisionmaking ability from consumers than is plausible due to bounded rationality. Proposals that seek to change the incentives of health care providers threaten to create conflicts of interest between doctors and patients. New approaches are desperately needed. This Article proposes a government-facilitated but market-based approach to improving efficiency in the private market for medical care that I call "relative value health insurance." This approach focuses on the "choice architecture" necessary to enable even boundedly rational patients to contract for an efficient level of health care services through their health insurance purchase decisions. It uses comparative effectiveness research, which the ACA funds at a significant level for the first time, to rate medical treatments on a scale of one to ten based on their relative value, taking into account expected costs and benefits. These relative value ratings would enable consumers to contract with insurers for different levels of medical care at different prices, reflecting different cost-quality trade-offs. The Article describes both the benefits of relative value health insurance and the impediments to its implementation. It concludes with a brief discussion of how relative value ratings could also help to rationalize expenditures on public health insurance programs.

Community consultation for prehospital research: experiences of study coordinators and principal investigators

OBJECTIVE

To assess principal investigators' and study coordinators' views and experiences regarding community consultation in a multicenter trial of prehospital treatment for status epilepticus conducted under an exception from informed consent for research in emergency settings.

METHODS

Principal investigators and study coordinators at all 17 hubs for the Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART) were invited to complete a web-based survey regarding community consultation at their site for RAMPART. Major domains included 1) perceived goals of community consultation, 2) experiences with and views of community consultation methods used, 3) interactions with IRB regarding community consultation, and 4) general satisfaction and lessons learned. Descriptive statistics were tabulated for Likert scale data; relevant themes were reported for text-based data.

RESULTS

Twenty-eight individuals (16 coordinators and 12 investigators) representing all 17 RAMPART hubs completed the survey. Respondents considered multiple community consultation goals to be important, with least support for the role of community consultation in altering study design. All sites used multiple methods (median = 5). The most widely used, and generally favored, method was attending previously scheduled meetings of existing groups. Respondents expressed frustration with low attendance and responsiveness at open public meetings.

CONCLUSIONS

Coordinators and investigators in this trial viewed community consultation efforts as successful but reported real challenges generating public interest. Individuals with the condition under study were found to be more engaged and supportive of the trial. Respondents endorsed numerous potential goals of the community consultation process and often combined methods to achieve these goals.

What states are doing to simplify health plan choice in the insurance marketplaces

The new health insurance marketplaces aim to improve consumers' purchasing experiences by setting uniform coverage levels for health plans and giving them tools to explore their options. Marketplace administrators may choose to limit the number and type of plans offered to further simplify consumer decision-making. This issue brief examines the policies set by some state-based marketplaces to simplify plan choices: adopting a meaningful difference standard, limiting the number of plans or benefit designs insurers may offer, or requiring standardized benefit designs. Eleven states and the District of Columbia took one or more of these actions for 2014, though their policies vary in terms of their prescriptiveness. Tracking the effects of these different approaches will enhance understanding of how best to enable consumers to make optimal health insurance purchasing decisions and set the stage for future refinements.

Misunderstanding the ‘‘nature’’ of co-management: a geography of regulatory science and indigenous knowledges (IK)

Governments, NGOs, and natural scientists have increased research and policy-making collaborations with Indigenous peoples for governing natural resources, including official co-management regimes. However, there is continuing dissatisfaction with such collaborations, and calls for better communication and mutual learning to create more ‘‘adaptive’’ co-management regimes. This, however, requires that both Western and Indigenous knowledge systems be equal participants in the ‘‘co-production’’ of regulatory data. In this article, I examine the power dynamics of one co-management regulatory regime, conducting a multi-sited ethnography of the practices of researching and managing one transnational migratory species, greater white-fronted geese (Anser albifrons frontalis), who nest where Koyukon Athabascans in Alaska, USA, practice subsistence. Analyzing the ethnographic data through the literatures of critical geography, science studies and Indigenous Studies, I describe how the practice of researching for co-management can produce conflict. ‘‘Scaling’’ the data for the co-management regime can marginalize Indigenous understandings of human– environment relations. While Enlightenment-based practices in wildlife biology avoid ‘‘anthropomorphism,’’ Indigenous Studies describes identities that operate through non-modern, deeply imbricated human–nonhuman identities that do not separate ‘‘nature’’ and ‘‘society’’ in making knowledge. Thus, misunderstanding the ‘‘nature’’ of their collaborations causes biologists and managers to measure and research the system in ways that erase how subsistence- based Indigenous groups already ‘‘manage’’ wildlife: by living through their ethical commitments to their fellow beings. At the end of the article, I discuss how managers might learn from these ontological and epistemologicaldifferences to better ‘‘co-produce’’ data for co-management.

Patient Protection and Affordable Care Act; Exchange functions: standards for Navigators and non-Navigator assistance personnel; consumer assistance tools and programs of an Exchange and certified application counselors. Final rule

This final rule addresses various requirements applicable to Navigators and non-Navigator assistance personnel in Federally-facilitated Exchanges, including State Partnership Exchanges, and to non-Navigator assistance personnel in State Exchanges that are funded through federal Exchange Establishment grants. It finalizes the requirement that Exchanges must have a certified application counselor program. It creates conflict-of-interest, training and certification, and meaningful access standards; clarifies that any licensing, certification, or other standards prescribed by a state or Exchange must not prevent application of the provisions of title I of the Affordable Care Act; adds entities with relationships to issuers of stop loss insurance to the list of entities that are ineligible to become Navigators; and clarifies that the same ineligibility criteria that apply to Navigators apply to certain non-Navigator assistance personnel. The final rule also directs that each Exchange designate organizations which will then certify their staff members and volunteers to be application counselors that assist consumers and facilitate enrollment in qualified health plans and insurance affordability programs, and provides standards for that designation.

Who governs federally qualified health centers?

To make them more responsive to their community's needs, federally qualified health centers (FQHCs) are required to have a governing board comprising at least 51 percent consumers. However, the extent to which consumer board members actually resemble the typical FQHC patient has not been assessed, which according to the political science literature on representation may influence the board's ability to represent the community. This mixed-methods study uses four years of data from the Health Resources and Services Administration, combined with Uniform Data System, Bureau of Labor Statistics, and Area Resource File data, to describe and identify factors associated with the composition of FQHC governing boards. Board members are classified into one of three groups: nonconsumers, nonrepresentative consumers (who do not resemble the typical FQHC patient), and representative consumers (who resemble the typical FQHC patient). The analysis finds that a minority of board members are representative consumers, and telephone interviews with a stratified random sample of thirty FQHC board members confirmed the existence of significant socioeconomic gaps between consumer board members and FQHC patients. This may make FQHCs less responsive to the needs of the predominantly low-income communities they serve.

Legislation on direct-to-consumer genetic testing in seven European countries

An increasing number of private companies are now offering direct-to-consumer (DTC) genetic testing services. Although a lot of attention has been devoted to the regulatory framework of DTC genetic testing services in the USA, only limited information about the regulatory framework in Europe is available. We will report on the situation with regard to the national legislation on DTC genetic testing in seven European countries (Belgium, the Netherlands, Switzerland, Portugal, France, Germany, the United Kingdom). The paper will address whether these countries have legislation that specifically address the issue of DTC genetic testing or have relevant laws that is pertinent to the regulatory control of these services in their countries. The findings show that France, Germany, Portugal and Switzerland have specific legislation that defines that genetic tests can only be carried out by a medical doctor after the provision of sufficient information concerning the nature, meaning and consequences of the genetic test and after the consent of the person concerned. In the Netherlands, some DTC genetic tests could fall under legislation that provides the Minister the right to refuse to provide a license to operate if a test is scientifically unsound, not in accordance with the professional medical practice standards or if the expected benefit is not in balance with the (potential) health risks. Belgium and the United Kingdom allow the provision of DTC genetic tests.

State health insurance exchange laws: the first generation

Health insurance exchanges are the centerpiece of the private health insurance reforms included in the Patient Protection and Affordable Care Act. As of May 2012, 13 states, together with the District of Columbia, had taken legal action to establish exchanges, through legislation or executive order. State implementing laws are essential to the translation of broad federal policies into specific state and market practices. Overall, the laws in the 14 jurisdictions vary, but they tend to show a common approach of according exchanges much flexibility in how they will operate and what standards they will apply to the insurance products sold. In all states, these "threshold policies" will be followed by policy decisions, expressed through regulations, guidelines, and health plan contracting and performance standards.

Medical loss ratio requirements under the Patient Protection and Affordable Care Act. Final rule

This final rule amends the regulations implementing medical loss ratio (MLR) standards for health insurance issuers under the Public Health Service Act in order to establish notice requirements for issuers in the group and individual markets that meet or exceed the applicable MLR standard in the 2011 MLR reporting year.

Patient Protection and Affordable Care Act; establishment of exchanges and qualified health plans; exchange standards for employers. Final rule, Interim final rule

This final rule will implement the new Affordable Insurance Exchanges ("Exchanges"), consistent with title I of the Patient Protection and Affordable Care Act of 2010 as amended by the Health Care and Education Reconciliation Act of 2010, referred to collectively as the Affordable Care Act. The Exchanges will provide competitive marketplaces for individuals and small employers to directly compare available private health insurance options on the basis of price, quality, and other factors. The Exchanges, which will become operational by January 1, 2014, will help enhance competition in the health insurance market, improve choice of affordable health insurance, and give small businesses the same purchasing clout as large businesses.

Patient Protection and Affordable Care Act; standards related to reinsurance, risk corridors, and risk adjustment. Final rule

This final rule implements standards for States related to reinsurance and risk adjustment, and for health insurance issuers related to reinsurance, risk corridors, and risk adjustment consistent with title I of the Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act of 2010, referred to collectively as the Affordable Care Act. These programs will mitigate the impact of potential adverse selection and stabilize premiums in the individual and small group markets as insurance reforms and the Affordable Insurance Exchanges ("Exchanges") are implemented, starting in 2014. The transitional State-based reinsurance program serves to reduce uncertainty by sharing risk in the individual market through making payments for high claims costs for enrollees. The temporary Federally administered risk corridors program serves to protect against uncertainty in rate setting by qualified health plans sharing risk in losses and gains with the Federal government. The permanent State-based risk adjustment program provides payments to health insurance issuers that disproportionately attract high-risk populations (such as individuals with chronic conditions).

Medicaid program; eligibility changes under the Affordable Care Act of 2010. Final rule, Interim final rule

This final rule implements several provisions of the Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act). The Affordable Care Act expands access to health insurance coverage through improvements to the Medicaid and Children's Health Insurance (CHIP) programs, the establishment of Affordable Insurance Exchanges ("Exchanges"), and the assurance of coordination between Medicaid, CHIP, and Exchanges. This final rule codifies policy and procedural changes to the Medicaid and CHIP programs related to eligibility, enrollment, renewals, public availability of program information and coordination across insurance affordability programs.

Health reform: special report. Health reform turns two: after passage of the Affordable Care Act, the work--and the criticisms--persist

NCSL tracks state actions on federal health reform closely. You can learn more about federal regulations, state legislation, Medicaid, insurance reform and more at www.ncsl.org/healthreform. Several NCSL health staff contributed to this package of stories related to the two-year anniversary of the Affordable Care Act. Contributors: Exchanges: job no. 1--Martha Salazar. Big changes for insurers--Richard Cauchi. Sharp divisions persist over law's future--Richard Cauchi. Transforming Medicaid--Melissa Hansen. States decided essential benefits--Richard Cauchi.

PREVENTION

more than an ounce--Amy Winerfeld. Help wanted: doctors and nurses--Laura Tobler.

Designing health insurance exchanges: key decisions

A cornerstone of health care reform is the establishment of state-level insurance exchanges where individuals and small businesses can purchase health insurance in an online marketplace. States are required to develop an exchange by 2014, or participate in a federal one. The exchanges will help people without employer-sponsored insurance find and choose a health plan to meet their needs. This Issue Brief reviews the experience of Massachusetts in developing a health insurance exchange and offers policymakers guidance on key features and likely consumer responses.

Comparison friction: experimental evidence from medicare drug plans

Consumers need information to compare alternatives for markets to function efficiently. Recognizing this, public policies often pair competition with easy access to comparative information. The implicit assumption is that comparison friction—the wedge between the availability of comparative information and consumers' use of it—is inconsequential because when information is readily available, consumers will access this information and make effective choices. We examine the extent of comparison friction in the market for Medicare Part D prescription drug plans in the United States. In a randomized field experiment, an intervention group received a letter with personalized cost information. That information was readily available for free and widely advertised. However, this additional step—providing the information rather than having consumers actively access it—had an impact. Plan switching was 28% in the intervention group, versus 17% in the comparison group, and the intervention caused an average decline in predicted consumer cost of about $100 a year among letter recipients—roughly 5% of the cost in the comparison group. Our results suggest that comparison friction can be large even when the cost of acquiring information is small and may be relevant for a wide range of public policies that incorporate consumer choice.

PGTandMe: social networking-based genetic testing and the evolving research model

The opportunity to use extensive genetic data, personal information, and family medical history for research purposes may be naturally appealing to the personal genetic testing (PGT) industry, which is already coupling direct-to-consumer (DTC) products with social networking technologies, as well as to potential industry or institutional partners. This article evaluates the transformation in research that the hybrid of PGT and social networking will bring about, and--highlighting the challenges associated with a new paradigm of "patient-driven" genomic research--focuses on the consequences of shifting the structure, locus, timing, and scope of research through genetic crowd-sourcing. This article also explores potential ethical, legal, and regulatory issues that arise from the hybrid between personal genomic research and online social networking, particularly regarding informed consent, institutional review board (IRB) oversight, and ownership/intellectual property (IP) considerations.

In courtroom 7--the Children's Koori Court at work: findings from an evaluation

This article reports some of the findings of an evaluation of the Children's Koori Court (CKC)--the first legislated effort in Australia to involve the Indigenous community in the sentencing of young Aboriginal offenders as a strategy for reducing their overrepresentation in the juvenile justice system. A prominent feature of this court of summary jurisdiction is that the presiding magistrate, while remaining the sentencing authority, is assisted by Aboriginal Elders. This article focuses on the evaluation findings that were derived from observations of the CKC in action. They indicate that the operational objective of cultural responsiveness was realized. They also point to realization of the community-building goal-fostering Indigenous ownership of the administration of the law. Little slippage was found between the CKC's design and operation, although some areas of improvement were identified. Nevertheless, the scope for the CKC by itself to significantly reduce overrepresentation is limited.

Local practice and global data: loyalty cards, social practices, and consumer surveillance

Monitoring of consumers has become the most widespread mode of surveillance today. Being a multi-billion dollar business, the collected data are traded globally without much concern by the consumers themselves. Loyalty cards are an element with which such data are collected. Analyzing the role of loyalty cards in everyday practices such as shopping, I discuss how new modes of surveillance evolve and work and why they eventually make communication about data protection a difficult matter. Further, I will propose an alternative approach to the study of surveillance. This approach is concerned with local practices, focusing on subjective narratives in order to view surveillance as an integral part of culturally or socially manifested contexts and actions and not to view surveillance as something alien to society and human interaction. This will open up other possibilities to study modes of subjectivity or how individuals situate themselves within society.

Planning, housing and participation in Britain, 1968-1976

The history of planning and social housing in post-war Britain has been dominated by the role of the state, local government, professionals (planners, architects, civil servants) and developers. This is hardly surprising, given that the partnerships created around these groups dominated the slum clearance and building process. The tenants have been absent from the 'history' because they were missing from the process. However, in the 1960s and 1970s the concept of participation began to emerge. It grew from broader social and cultural changes brought about through the emergence of welfare, consumerism and an ever greater awareness of 'rights'. The idea of participation was to increase participatory democracy by involving people in the planning process, by recognizing their rights to be involved in decisions which impacted on their lives. The state promoted the idea through legislation, but in practice the concept proved difficult to implement. Local authorities saw participation, at best, as a means of smoothing the planning process through the dissemination of ideas, thus limiting any scope for meaningful participation schemes. This article will look at the tension between the ideal and practice. It will also consider the reaction of many tenants who, frustrated at the attitude and policies forced on them by local government, became galvanized into action, creating tenant groups that would give their communities a voice.

Shifting subjects of health-care: placing "medical tourism" in the context of Malaysian domestic health-care reform

"Medical tourism" has frequently been held to unsettle naturalised relationships between the state and its citizenry. Yet in casting "medical tourism" as either an outside "innovation" or "invasion," scholars have often ignored the role that the neoliberal retrenchment of social welfare structures has played in shaping the domestic health-care systems of the "developing" countries recognised as international medical travel destinations. While there is little doubt that "medical tourism" impacts destinations' health-care systems, it remains essential to contextualise them. This paper offers a reading of the emergence of "medical tourism" from within the context of ongoing health-care privatisation reform in one of today's most prominent destinations: Malaysia. It argues that "medical tourism" to Malaysia has been mobilised politically both to advance domestic health-care reform and to cast off the country's "underdeveloped" image not only among foreign patient-consumers but also among its own nationals, who are themselves increasingly envisioned by the Malaysian state as prospective health-care consumers.

The perceived implications of an outsourcing model on governance within British Columbia Provincial Parks in Canada: a quantitative study

Good governance is of paramount importance to the success of parks and protected areas. This research utilized a questionnaire for 10 principles of governance to evaluate the outsourcing model used by British Columbia Provincial Parks, where profit-making corporations provide all front country visitor services. A total of 246 respondents representing five stakeholder groups evaluated the model according to each principle, using an online survey. Principal component analysis resulted in two of the 10 principles (equity and effectiveness) each being split into two categories, leading to 12 governance principles. Five of the 12 criteria received scores towards good governance: effectiveness outcome; equity general; strategic vision; responsiveness; and effectiveness process. One criterion, public participation, was on the neutral point. Six criteria received scores below neutral, more towards weak governance: transparency; rule of law; accountability; efficiency; consensus orientation; and, equity finance. The five stakeholder groups differed significantly on 10 of the 12 principles (P < .05). The 2 exceptions were for efficiency and effectiveness process. Seven of the 12 criteria followed a pattern wherein government employees and contractors reported positive scores, visitors and representatives of NGOs reported more negative scores, and nearby residents reported mid-range scores. Three criteria had government employees and contractors reporting the most positive scores, residents and visitors the most negative scores, and NGO respondents reporting mid-range scores. This research found evidence that perceptions of governance related to this outsourcing model differed significantly amongst various constituent groups.

Health care reform insurance Web portal requirements. Interim final rule with comment period

The Patient Protection and Affordable Care Act (the Affordable Care Act) was enacted on March 23, 2010. It requires the establishment of an internet Web site (hereinafter referred to as a Web portal) through which individuals and small businesses can obtain information about the insurance coverage options that may be available to them in their State. The Department of Health and Human Services (HHS) is issuing this interim final rule in order to implement this mandate. This interim final rule adopts the categories of information that will be collected and displayed as Web portal content, and the data we will require from issuers and request from States, associations, and high risk pools in order to create this content.

Direct-to-consumer advertising of prescription drugs

In 2007, the pharmaceutical industry spent more than $4.9 billion on direct-to-consumer advertising (DTCA) of prescription drugs in the U.S. Controversy over DTCA has grown since the Food and Drug Administration liberalized its regulations in 1997. Proponents claim that such advertising educates consumers, promotes patient participation in clinical decisions, and improves patient adherence to medication instructions. Opponents argue that such advertising is meant to persuade, not educate, and that it promotes inappropriate use of prescription drugs, or diverts consumers from better alternatives. This Issue Brief summarizes the evidence about the effects of DTCA, and proposes guidelines for improving the utility of prescription drug advertising.

Public participation in post-Fordist urban green space governance: the case of community gardens in Berlin

This article examines citizen participation in the governance of contemporary urban green space. Rather than exploring normative questions of ideal forms of participatory democracy, it focuses on changing roles and relationships between local state and non-state actors in order to identify and explain the changing nature of participation. I argue that neoliberal urban restructuring has changed the conditions for participation and thus participation itself in fundamental ways and that we need an account of changes in statehood and governance in order to capture this conceptually. Based on the case of community gardens in Berlin, the article discusses the extent to which this changed relationship is expressed by current citizen participation as well as the potential and problems that result from it. My empirical results show the emergence of a new political acceptance of autonomously organized projects and active citizen participation in urban green space governance. The central argument of this article is that this new acceptance can be conceptualized as an expression of the neoliberalization of cities. Nevertheless, this neoliberal strategy at the same time leads to complex and contradictory outcomes and the resulting benefits are also acknowledged.

Denial of the child's right to counsel, voice, and participation in juvenile delinquency proceedings

Article 12 of the United Nations Convention on the Rights of the Child clearly recognizes the importance of the child's voice in judicial proceedings that affect him or her. Nowhere is the child's voice more important than in delinquency proceedings where decisions will be made about the child's liberty, rehabilitative prospects, and other important constitutional rights. This article examines the role of the child's voice in improving fairness and accuracy in adjudicatory and dispositional decisions and enhancing therapeutic outcomes for youth in juvenile court.