The Trump administration's immigration crackdown may be leading to an unintended consequence: a drop-off in benefits enrollment among legal Hispanic immigrants, according to new research by Stanford Health Policy's Marcella Alsan.

This CBS News story about her work notes that an immigration program called Secure Communities, which was rolled out during the Obama administration, is linked to a lower take-up of benefits such as food stamps and health care enrollment.

In a new paper published by the National Bureau of Economic Research, Alsan and Crystal Yang of Harvard Law School found Hispanic households were particularly hard-hit, even those with legal immigration status.

"We find evidence that our results may be driven by deportation fear rather than lack of benefit information or stigma," the researchers wrote.  "Though not at personal risk of deportation, Hispanic citizens may fear their participation could expose non-citizens in their network to immigration authorities. We find significant declines in SNAP and ACA enrollment, particularly among mixed-citizenship status households and in areas where deportation fear is highest."

Read the CBS News story.

A new calculation that combines health and economic well-being at the population level could help to better measure progress toward the U.N. Sustainable Development Goals and illuminate major disparities in health and living standards across countries, and between men and women, according to a new study by Stanford and Harvard researchers.

In a study released this month in The Lancet Global Health, Joshua Salomon, a professor of medicine and core faculty member at Stanford Health Policy, finds there are startling differences between countries in the number of years people can expect to survive free from poverty, much greater than the differences observed in life expectancy alone, and that women surrender more years of life to poverty than men in much of the world.

At the U.N. Sustainable Development Summit in 2015, world leaders adopted the Sustainable Development Goals (SDGs) as the embodiment of the global agenda for development through 2030. One of the 17 goals calls for universal health coverage, including financial risk protection, which highlights the explicit link between economic and health development policies.

“Despite this link, and despite the multitude of targets and indicators established through the SDGs and other global initiatives, most monitoring and benchmarking efforts rely on metrics that are highly specific to a single dimension of interest,” Salomon and his colleagues from the Harvard T.H. Chan School of Public Health wrote in the Lancet study.

Such an approach misses opportunities to understand the broader impact of development policies as they affect the well-being of populations in multiple ways.

So, the researchers developed a population-level measure of poverty-free life expectancy (PFLE) and computed the measurements for 90 countries with available data. They used Sullivan's method to incorporate the prevalence of poverty by age and sex from household economic surveys into demographic life tables based on mortality rates that are routinely estimated for all countries. Poverty-free life expectancy for each country is the average number of years people could expect to survive with adequate income to meet their basic needs, given current mortality rates and poverty prevalence in that country.

The authors found that PFLE varies widely between countries, ranging from less than 10 years in Malawi to more than 80 years in countries such as Iceland.  In 67 of 90 countries, the difference between life expectancy and PFLE was greater for females than for males, indicating that women generally surrender more years of life to poverty than men do. 

In some African countries, people can expect to live more than half of the total lifespan in poverty.

“This new indicator can aid in monitoring progress toward the linked global agendas of health improvement and poverty elimination and can strengthen accountability for development policies,” the authors wrote.

Despite general improvements in survival in most regions of the world in the past decades, the focus in the Sustainable Development Goals era on ending poverty “brings into sharp relief the importance of ensuring that years of added life are lived with at least a minimum standard of economic well-being.”

Salomon said the researchers hope the development of a new, simple measure that summarizes overall health and economic welfare in a single number can do two things.

“One is to help encourage leaders to be transparent and accountable to the populations they serve through regular tracking and reporting on overall progress toward longer and better lives,” he said. “The other is to bring measurement out of the silos of individual sectors, to highlight both the need for multisectoral action to improve health and welfare and the connections between health and economic consequences of public policy.”

Malaria claims nearly half-a-million lives worldwide each year — and yet we still know so little about the immunology of the disease that has plagued humanity for centuries.

There were 216 million cases in 2016, according to the World Health Organization. Sub-Saharan Africa carries 80 percent of the global burden of the mosquito-borne infectious disease which devastates families, disrupts education, and promotes the vicious cycle of poverty.

It is particularly brutal to pregnant women, who are three times more likely to suffer from a severe form of the disease, leading to lower birthweight among their newborns and higher rates of miscarriage, premature and stillborn deliveries.

“Pregnant women and their unborn children are more susceptible to the adverse consequences of malaria, so we are working to investigate new strategies and even lay the foundation for a vaccine to prevent malaria in pregnancy,” said Prasanna Jagannathan, MD, an assistant professor of medicine who is this year’s recipient of the Rosenkranz Prize.

Jagannathan, an infectious disease physician who is also a member of Stanford’s Child Health Research Institute, said the $100,000 stipend that comes with the prize will allow his lab members to ramp up their research in Uganda. A member of the nonprofit Infectious Disease Research Collaboration in Kampala, his team is particularly interested in how strategies that prevent malaria might actually alter the development of natural immunity to malaria.

“With support from the Rosenkranz Prize, we hope to identify maternal immune characteristics and immunologic targets that are associated with protection of malaria in pregnancy and infancy,” Jagannathan said.

The Dr. George Rosenkranz Prize for Health Care Research in Developing Countries is awarded each year by the Freeman Spogli Institute for International Studies and Stanford Health Policy to a young Stanford researcher who is trying to improve health care in underserved countries. It was established in 2009 by the family or Dr. George Rosenkranz, a chemist who first synthesized cortisone in 1951, and later progesterone, the active ingredient in oral birth control pills.

“My father has held a lifelong commitment to scientific research as a way to improve the lives and well-being of communities around the world,” said Ricardo T. Rosenkranz, MD. “In particular, he has always sought to improve the health of at-risk populations. Dr. Jagannathan’s work offers the very sort of innovative ingenuity that characterized my father’s early research, as well as his vision towards the future.”

Jagannathan and his collaborators at UCSF and in Uganda are currently conducting a randomized control trial of 782 Ugandan women who are receiving intermittent preventive treatment with a fixed dose of dihydroartemisinin-piperaquine(or IPTp-DP), a medication that has dramatically reduced the risk of maternal parasitemia, anemia, and placental malaria. Their preliminary data suggests that among 684 infants born to these women, maternal receipt of IPTp-DP may lead to a reduced incidence of malaria in the first year of life.

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“Having the discretionary support of the Rosenkranz Prize will allow us to generate some preliminary ideas from this trial that could lead to larger studies, to push this agenda further along,” Jagannathan said.

That agenda is to create a vaccine that targets pregnant women to prevent malaria both during pregnancy — but also potentially preventing malaria in infants, giving them a better start in life.

“We’re not the first ones to think of this, but we have the opportunity to test these hypotheses in incredibly unique settings, with really well-studied cohorts that have real-world implications in terms of what we find,” Jagannathan said. “I’m hopeful that the data that’s generated over the new few years will allow us to keep moving forward.”

Jagannathan has been traveling to Uganda for a decade to study malaria. He’s seen firsthand the relentless, gnawing impact the disease has on daily life.

“Before I went to Uganda I really didn’t understand the burden that malaria causes in communities — and it’s just incredible,” he said. His first study was on children aged 5 and under who had on average six episodes of malaria a year.

“They just get it over and over again, and the toll on society is enormous,” he said. The clinics are overwhelmed and a parent or sibling must miss work or school to stay home with that child.

Yet, in highly endemic settings, children eventually develop an immunity that protects against the adverse outcomes from malaria. If he and his colleagues can understand how pregnant women and children develop this clinical immunity to malaria, it could lead to better treatments and preventative strategies.

“If we understand the mechanisms that underlie naturally acquired immunity, that would offer some clues as to how we can develop a vaccine that actually allows either that immunity to occur more quickly or prevents us from developing immunity that allows for the parasite to persist without symptoms,” he said.

There is currently a malaria vaccine undergoing testing in Africa. The vaccine, known as RTS,S, was developed by GlaxoSmithKline and the PATH Malaria Vaccine Initiative, with support from the Bill and Melinda Gates Foundation. Decades in the making, four doses of the vaccine are required to reduce malaria infection in humans.

“It’s a remarkable vaccine in that it’s effective in the beginning, but the problem is that the efficacy wanes very rapidly,” Jagannathan said, noting that some studies show that beyond three years, the effectiveness drops to 15-20 percent.

“That’s the big issue and why people are really interested in trying to find new strategies and new approaches for a next-generation malarial vaccine,” he said. “That’s the overarching aspect of what motivates my work.”

The rising level of carbon dioxide in the atmosphere means that crops are becoming less nutritious, and that change could lead to higher rates of malnutrition that predispose people to various diseases.

That conclusion comes from an analysis published Tuesday in the journal PLOS Medicine, which also examined how the risk could be alleviated. In the end, cutting emissions, and not public health initiatives, may be the best response, according to the paper's authors, which includes Stanford Health Policy's Eran Bendavid and Sanjay Basu.

Research has already shown that crops like wheat and rice produce lower levels of essential nutrients when exposed to higher levels of carbon dioxide, thanks to experiments that artificially increased CO2 concentrations in agricultural fields. While plants grew bigger, they also had lower concentrations of minerals like iron and zinc.

Read the story at NPR

The health insurance marketplaces created by the Affordable Care Act (ACA) could unravel because its enrollees strategically drop in and out of coverage, Stanford scholars write in a new working paper released June 4 by the National Bureau of Economic Research.

The end result could be a complete unraveling of the market, said Petra Persson, an assistant professor of economics in the Stanford School of Humanities and Sciences.

“If you have too many people who drop out after a few months of coverage, you might end up in a situation where insurers don’t want to offer any insurance at all in the market,” said Persson, who co-authored the paper with Stanford Graduate School of Business assistant professors Rebecca Diamond and Timothy McQuade and NYU Stern’s Michael J. Dickstein. Persson and Diamond are also fellows at the Stanford Institute for Economic Policy Research.

The ACA, also known as Obamacare, passed in March 2010 with the goal of making health insurance more accessible. It established a competitive marketplace where individuals could shop for federal and state-level health care plans. Over 2014 and 2015 – the first two years of the program – the share of Americans covered by individually purchased health insurance rose by 50 and 75 percent, respectively.

Health care consumption surged, especially in low-income households and families with young children. But, as the researchers discovered, so did attrition: Dropout was sharpest after just one month of coverage. And only half of all new enrollees committed a full year to an insurance program.

Health care consumption and attrition

To analyze enrollment and attrition, the researchers studied 104,233 households that purchased health insurance in California either before or after the ACA came into effect.

The researchers examined spending habits and income sources for possible explanations of why people might have discontinued health care coverage. For example, did they drop out because they could no longer afford it, because of a job loss or other large expense?

The researchers found that this was the case before the ACA came into effect. Pre-ACA, people often dropped out early because they experienced a loss of income, like unemployment. But post-ACA, the loss of income was much less important in explaining early dropout.

“These findings indicate that the ACA limited the risk of being forced to drop insurance coverage due to unexpected liquidity shocks,” said Persson.

If income shocks can’t account for dropout, then what can?

The researchers found that some people strategically drop coverage after they have used the health care services they need.

“Our analysis shows that many consumers are strategically signing up for insurance to help defray the costs of non-chronic, potentially discretionary, health care needs and then dropping coverage once they have satisfied these needs,” said Diamond.

“The regulatory structure of the ACA law potentially incentivizes exactly this behavior,” the researchers wrote, noting that because the ACA prevents insurers from discriminating against applicants, they cannot legally reject applicants who strategically dropped coverage the previous year.

The fallout of dropouts

This behavior makes it difficult for insurers to set prices, said Persson.

When people consume a year’s worth of health care in only a three-month period – and only pay a portion of the annual premium – it can be incredibly expensive for insurers. They can only guess what fraction of policyholders will end up dropping out mid-year.

The researchers discovered a counterintuitive response from insurers: Health care plans that experienced more dropouts reduced their premium prices the following year.

“Insurers are trying to increase the demand from the pool of consumers who don’t drop out,” said Diamond, observing that these are the people who are more price sensitive to the cost of an annual plan. “People who drop out are going to be less sensitive to the price set by the plan. They are always going to be willing to pay a higher monthly premium because they know they are not going to pay the full annual amount.”

While lowered annual premiums may seem like a beneficial result for committed health care consumers, the presence of dropouts undermines the stability of the market, the researchers said. As a result, insurers may be unwilling to offer plans in the individual market, they said.

Next steps

The ACA has been especially effective in providing lower-income households with health care coverage through a market that previously had largely served more affluent households, said Persson.

But for ACA to continue being effective, enrollees must stay enrolled, Persson added.

While the ACA originally came with penalties for ceasing coverage early, the researchers said it was not enough. It was still cheaper for new enrollees to pay the fine for dropping out mid-year than paying a full year of annual premiums, the researchers found in their cost analysis.

The recent removal of the individual mandate will likely increase the midyear dropout rate, said Diamond. “More dropout will raise financial pressure on insurers, increasing the possibility that the market unravels completely.”

Cuts to Medicaid hurt all children — rich and poor. Because hospitals that deal with serious childhood injuries and illnesses depend on the public funding as much as those poor families who get medical care under the government insurance program.

That’s the message that Stanford Health Policy’s Lisa Chamberlain, Olga Saynina and Paul Wise and will be presenting at the Pediatric Academic Societies meeting in Toronto later this week. The PAS conference is the leading event for academic pediatrics and child health research. Chamberlain and Wise are Stanford Medicine pediatricians and Saynina is a data research analyst with Stanford Health Policy.

New research by the Stanford team shows that proposals to dramatically reduce federal expenditures on Medicaid and CHIP — the Children’s Health Insurance Program — could destabilize current specialty care referral networks for all children. This includes a large subset of privately-insured children in greatest need of high quality, specialized pediatric care.

“Most people think of Medicaid as a safety-net program, and to a certain extent it is,” said Wise, a core faculty member at SHP and the Center on Democracy, Development, and the Rule of Law, as well as a senior fellow at the Freeman Spogli Institute for International Health.

“But it has become so important to child-health systems that rich kids — kids with good commercial insurance — are heavily dependent on specialized care if they really get sick, on facilities that are heavily dependent on Medicaid,” he said.

Nearly one out of every five children live below the poverty line, according to the U.S. Census Bureau, yet few children need extensive health care. But of those who do, about 44 percent rely on Medicaid or other public insurance programs, regardless of their family’s income.

“Caring for seriously ill children requires a wide range of services and specialists, from pediatric surgeons to speech therapists to hospital teachers who make sure kids don’t fall behind,” Chamberlain told SHP for this story last year. “In pediatrics, we work as a team — and cutting Medicaid will reduce our ability to do that.”

The Stanford group analyzed two large datasets: the 2012 national Kids’ Inpatient Databaseand the 2012 California Patient Discharge Database. They found that hospitals caring for children with serious, chronic illnesses — such as congenital heart disease, cancer and severe asthma — are highly dependent on public payers such as Medicaid.

Nationally, major pediatric hospitals reported 55 percent of bed-days were covered by public payers, with the 10-highest volume hospitals ranging from 36 to 100 percent.   Overall, in California for all hospitals, 30 percent of net revenue is derived from Medicaid and for children’s hospitals, Medicaid provides 56 percent of net revenue.

Paul H. Wise, the Richard E. Behrman Professor of Child Health and Society, professor of pediatrics, and a Senior Fellow in the Freeman Spogli Institute for International Studies, is elected to the 2018 membership class of the American Academy of Arts and Sciences. His work focuses on health inequalities, maternal and child health policy, and children's health in areas of violent conflict, political instability and weak governance.

In this video, we ask him about the honor and what he hopes to achieve through membership in the prestigious organization founded in 1780 and devoted to the advancement and study of key societal, scientific and intellectual issues of the day.

"The recognition is important, but I see it as being more important as a platform for continuing to act in the real world; that it provides some semblance of enhanced legitimacy to speak to issues of global importance," says Wise, who is a core faculty member at Stanford Health Policy.

Renowned economist Jeffrey Sachs launched an ambitious — some would say audacious — experiment back in 2005 in his quest to prove that we can end global poverty if we take a holistic, community-led approach to sustainable development.

The Millennium Villages Project targeted more than a dozen sub-Saharan villages and imposed an integrated approach to help these villages achieve the U.N. Millennium Development Goals to address poverty, health, gender equality, and disease.

Funded by World Bank loans, governments, and private contributions, the pilot wanted to see whether conditions would improve dramatically for the half-million residents of the villages in the 10 project sites by improving access to safe drinking water, primary education, basic health care, and other science-based interventions such as better seeds and fertilizer.

The results are in. And boy are they are mixed.

Some harsh critics say the MVP was a waste of hundreds of millions of dollars, the project was riddled with fundamental methodological errors, and there is little scientific evidence that the project attained its goals.

Others, such as Sachs himself in this Lancet Global Health perspective, say that while the outcomes on poverty were mixed and impacts on nutrition and education often inconclusive, “the lessons learned from the MVP are highly pertinent.”

Stanford Health Policy’s Eran Bendavid — asked to contribute a commentary about the endline evaluation of the project published online this month in The Lancet Global Health — falls somewhere between critic and advocate.

"The project, set up as a focused set of interventions implementing an important idea in international development about how to best help the poor, was a terrific opportunity for learning about how to reduce poverty and improve well-being,” Bendavid said.

But the MVP was not set up as a randomized field trial, nor was there any monitoring of what happened in any comparison areas to make sense of what the intervention had achieved.

“No comparison sites were selected either. That was a wasted opportunity,” he said. “The endline evaluation of the project does the best that can be done to eek some information from the limited opportunities for learning.”

Bendavid, an associate professor of medicine and an infectious diseases physician who focuses on global health, said the project invested about $120 per person per year for 50,000 people for 10 years. That’s about $600 million.

“The clearest evidence of benefits from this investment is improved maternal health-care and health outcomes,” he said.

The authors of the final evaluation tried to put a better spin on the net benefits.

“We found that impact estimates for 30 of 40 outcomes were significant and favored the project villages,” wrote the authors of The Millennium Villages Project: a retrospective, observational, endline evaluation.

“In particular, substantial effects were seen in agriculture and health, in which some of the outcomes were roughly one (standard deviation) better in the project villages than in the comparison villages,” they wrote. However, they added, “The project was estimated to have no significant impact on the consumption-based measures of poverty,” and impacts on nutrition and education outcomes were often inconclusive.

But when they averaged outcomes within categories, the authors — of whom Sachs was one — concluded that the project had significant favorable impacts on agriculture, nutrition, education, child health, maternal health, HIV and malaria, and water and sanitation.

In all, a third of the targets of the Millennium Development Goals were met in the project sites.

Bendavid concluded that the endline evaluation “marks an important chapter in our understanding of Africa’s meandering path towards health and economic development.” 

He noted that the project’s evaluation, which was done as well as possible given the difficulties of assessing its impact 10 years on, still failed to shed much light on the MVP’s approach as a method to bring an end to poverty. 

“This was such an important project,” Bendavid said. “We’ll never fully know where it succeeded and where it did not, but this evaluation is a welcome bookend to what we are likely to ever learn from that experience.”

Listen to a podcast with Bendavid.

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