Michael D. Rozier’s research while affiliated with Monash University (Australia) and other places

Context: Health foundations provide significant financial resources for community health. Foundation priorities, therefore, can play a key role in setting community agenda, but little is known about the criteria foundations use to prioritize projects. Objective: To understand the priorities that guide decision makers in health foundations and compare those priorities with what is known about nonprofit hospitals, public health, and community-based nonprofits. Design: An online survey with a discrete choice experiment and open-ended questions, asking respondents to choose between different types of community health projects based on project characteristics. Setting: Survey respondents were employed by health foundations located in the United States. Participants: Respondents were leaders at health foundations (n = 173), the majority of which (56.2%) worked at foundations with assets greater than $50 million. These respondents were compared with an earlier survey (n = 561) from nonprofit hospitals, public health, and community-based nonprofits. Main outcome measures: A conditional logit model was used to estimate how various project characteristics led to greater or lesser support of a given health project. Open-ended questions aided interpretation. A two sample t test was used to compare groups. Results: Foundation decision makers placed the greatest value on programs with coalitions of community partners, programs with a growing or existing base of evidence for effectiveness, and programs that focus on social determinants of health. These priorities are similar to those of community nonprofits, public health departments, and health systems. However, foundation leaders are more willing to fund interventions with longer time horizons and interventions that are not yet fully evidence-based. Foundations are also less interested in clinical care and more interested in advocacy programs. Conclusion: Cooperation in funding and implementation is essential to community health improvement, and major organizations could benefit from everyone clearly articulating their priorities. There are good reasons to intentionally foster both similarities and differences in priorities across organizations.

Policy Points Electronic health records (EHRs) are subject to the implicit bias of their designers, which risks perpetuating and amplifying that bias over time and across users. If left unchecked, the bias in the design of EHRs and the subsequent bias in EHR information will lead to disparities in clinical, organizational, and policy outcomes. Electronic health records can instead be designed to challenge the implicit bias of their users, but that is unlikely to happen unless incentivized through innovative policy. Context: Health care delivery is now inextricably linked to the use of electronic health records (EHRs), which exert considerable influence over providers, patients, and organizations. Methods: This article offers a conceptual model showing how the design and subsequent use of EHRs can be subject to bias and can either encode and perpetuate systemic racism or be used to challenge it. Using structuration theory, the model demonstrates how a social structure, like an EHR, creates a cyclical relationship between the environment and people, either advancing or undermining important social values. Findings: The model illustrates how the implicit bias of individuals, both developers and end-user clinical providers, influence the platform and its associated information. Biased information can then lead to inequitable outcomes in clinical care, organizational decisions, and public policy. The biased information also influences subsequent users, amplifying their own implicit biases and potentially compounding the level of bias in the information itself. The conceptual model is used to explain how this concern is fundamentally a matter of quality. Relying on the Donabedian model, it explains how elements of the EHR design (structure), use (process), and the ends for which it is used (outcome) can first be used to evaluate where bias may become embedded in the system itself, but then also identify opportunities to resist and actively challenge bias. Conclusions: Our conceptual model may be able to redefine and improve the value of technology to health by modifying EHRs to support more equitable data that can be used for better patient care and public policy. For EHRs to do this, further work is needed to develop measures that assess bias in structure, process, and outcome, as well as policies to persuade vendors and health systems to prioritize systemic equity as a core goal of EHRs.

Using moral foundations theory (MFT), this study analyzes how Republican governors employed moral concepts to either build support or opposition to Medicaid expansion. The study examined statements about Medicaid expansion made by all Republican governors as reported in two large newspapers in each governor’s state from 28 June 2012 to 31 December 2018. A slight majority of the statements (183 or 58.5%) used moral arguments in support of Medicaid expansion. Governors from both policy camps most frequently used the moral foundations shared by liberals and conservatives: care/harm and fairness/cheating. Those supporting expansion also used loyalty/betrayal, authority/subversion, and sanctity/degradation. Those opposing expansion used liberty/oppression. Policymakers recognize that activating the public’s moral intuitions can be an effective way to advance a policy of interest. Those interested in advancing health policies would do well to better understand the kind of moral arguments that are used with potential supporters and arguments that may be used by opponents.

Theological and secular voices in bioethics have drifted into separate silos. Such a separation results in part from (1) theologians focusing less on conveying ideas in ways that contribute to a pluralistic and public bioethical discourse and (2) the dwindling receptivity of religious arguments within secular bioethics. This essay works against these drifts by putting forward an argument that does not bounce around a religious echo-chamber, but instead demonstrates how insights of Christian anthropology can be meaningfully responsive to secular bioethics' rightful concerns with inequality and injustice. We offer core concepts from Christian bioethics that encourage dialogue with secular and theological bioethicists. The theologically-grounded concepts, human dignity, sin, and the common good, provide intellectual resources to address major areas of bioethical concern that remain unresolved.

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

Background: U.S. nonprofit hospital community benefit recently underwent significant regulatory revisions. Starting in 2009, the Internal Revenue Service (IRS) required hospitals to submit a new Schedule H that provided greater detail on community benefit activities. In addition, the Affordable Care Act (ACA), which became law in 2010, requires hospitals to conduct community health needs assessments (CHNA) and develop community health implementation plans (CHIP) as a response to priority needs every 3 years. These new requirements have led to greater transparency and accountability and this scoping review considers what has been learned about community benefit from 2010 to 2019. Methods: This review identified peer-reviewed literature published from 2010 to 2019 using three methods. First, an OvidSP MEDLINE search using terms suggested previously by community benefit researchers. Second, a PubMed search using keywords frequently found in community benefit literature. Third, a SCOPUS search of the most frequently cited articles in this topic area. Articles were then selected based on their relevance to the research question. Articles were organized into topic areas using a qualitative strategy similar to axial coding. Results: Literature appeared around several topic areas: governance; CHNA and CHIP process, content, and impact; community programs and their evaluation; spending patterns and spending influences; population health; and policy recommendations. The plurality of literature centered on spending and needs assessments, likely because they can draw upon publicly available data. The vast majority of articles in these areas use spending data from 2009 to 2012 and the first cycle of CHNAs in 2013. Policy recommendations focus on accountability for impact, enhancing collaboration, and incentivizing action in areas other than clinical care. Discussion: There are several areas of community benefit in need of further study. Longitudinal studies on needs assessments and spending patterns would help inform whether organizations have changed and improved operations over time. Governance, program evaluation, and collaboration are some of the consequential areas about which relatively little is known. Gaps in knowledge also exist related to the operational realities that drive community benefit activities. Shaping organizational action and public policy would benefit from additional research in these and other areas.

The 2012 Supreme Court decision in National Federation of Independent Business v Sebelius gave states the option to adopt the Medicaid expansion as part of the Affordable Care Act. Many states, especially those under Republican control, have since grappled with their decision to implement the expansion. We conduct a comparative analysis of how Republican governors framed their stance on the Medicaid expansion. We analyze public statements on the Medicaid expansion published in two major in-state newspapers from all Republican governors from June 2012 through June 2018. In total we collected, coded and analyzed 3277 statements from 66 newspapers. Several key themes emerge from our analysis. While every Republican governor used oppositional framing as part of their rhetorical response to the Medicaid expansion, the policy had a destabilizing effect on the previously unified opposition to health reform. We find that Republican framing split after the results of the 2012 election and that overall Republican governors shifted towards more supportive framing prior to the 2016 presidential election. Republican governors transformed how they framed their stance towards Medicaid expansion after Donald Trump was elected in 2016, with both supportive and oppositional moral-based framing of expansion increasing. These findings inform how policymakers use rhetoric to support their stance on controversial policies in a hyper-partisan and polarized political environment.

Global public health has several persistent challenges that require partnerships to properly solve. A global institution with the resources and influence of the Catholic Church, even though its health-related efforts have traditionally focused on the provision of direct medical care, could be a more valuable partner for global public health than it traditionally has been. The challenges are not technical in nature, but are conceptual ones that prevent global public health from achieving its full potential. For example, the intellectual resources of the Church could help cultivate a sense of vocation among public health professionals, similar to the awareness of vocation enjoyed in healing professions. Additionally, the social teaching of the Church, particularly the preferential option for the poor, could help shift the enduring issue that global resources often flow where they are least needed. Further, dignity and solidarity could provide the conceptual grounding needed to invest more energy in capacity building in low-resource settings. Such efforts also require conversion within the Church itself, suggesting that deeper partnership could benefit both the Church and global public health.