Large-scale public policy changes are often recommended to improve public health. Despite varying widely—from tobacco taxes to poverty-relief programs—such policies present a common dilemma to public health researchers: how to evaluate their health effects when randomized controlled trials are not possible. Here, we review the state of knowledge and experience of public health researchers who rigorously evaluate the health consequences of large-scale public policy changes. We organize our discussion by detailing approaches to address three common challenges of conducting policy evaluations: distinguishing a policy effect from time trends in health outcomes or preexisting differences between policy-affected and -unaffected communities (using difference-in-differences approaches); constructing a comparison population when a policy affects a population for whom a well-matched comparator is not immediately available (using propensity score or synthetic control approaches); and addressing unobserved confounders by utilizing quasi-random variations in policy exposure (using regression discontinuity, instrumental variables, or near-far matching approaches).

Socioeconomic disadvantage is a fundamental cause of morbidity and mortality. One of the most important ways that governments buffer the adverse consequences of socioeconomic disadvantage is through the provision of social assistance. We conducted a systematic review of research examining the health impact of social assistance programs in high-income countries. We systematically searched Embase, Medline, ProQuest, Scopus, and Web of Science from inception to December 2017 for peer-reviewed studies published in English-language journals. We identified empirical patterns through a qualitative synthesis of the evidence. We also evaluated the empirical rigour of the selected literature. Seventeen studies met our inclusion criteria. Thirteen descriptive studies rated as weak (n = 7), moderate (n = 4), and strong (n = 2) found that social assistance is associated with adverse health outcomes and that social assistance recipients exhibit worse health outcomes relative to non-recipients. Four experimental and quasi-experimental studies, all rated as strong (n = 4), found that efforts to limit the receipt of social assistance or reduce its generosity (also known as welfare reform) were associated with adverse health trends. Evidence from the existing literature suggests that social assistance programs in high-income countries are failing to maintain the health of socioeconomically disadvantaged populations. These findings may in part reflect the influence of residual confounding due to unobserved characteristics that distinguish recipients from non-recipients. They may also indicate that the scope and generosity of existing programs are insufficient to offset the negative health consequences of severe socioeconomic disadvantage.

A startling population health phenomenon has been unfolding since the turn of the 21st century. Whites in the United States, who customarily have the most favorable mortality profile of all racial groups, have experienced rising mortality rates, without a commensurate rise in other racial groups. The two leading hypotheses to date are that either contemporaneous economic conditions or longer-term (post-1970s) economic transformations have led to declining economic and social prospects of low-educated whites, culminating in "deaths of despair." We re-examine these hypotheses and investigate a third hypothesis: mortality increases are attributable to (false) perceptions of whites that they are losing social status. Using administrative and survey data, we examined trends and correlations between race-, age- and, education-specific mortality and a range of economic and social indicators. We also conducted a county-level fixed effects model to determine whether changes in the Republican share of voters during presidential elections, as a marker of growing perceptions of social status threat, was associated with changes in working-age white mortality from 2000 to 2016, adjusting for demographic and economic covariates. Rising white mortality is not restricted to the lowest education bracket and is occurring deeper into the educational distribution. Neither short-term nor long-term economic factors can themselves account for rising white mortality, because parallel trends (and more adverse levels) of these factors were being experienced by blacks, whose mortality rates are not rising. Instead, perceptions - misperceptions - of whites that their social status is being threatened by their declining economic circumstances seems best able to reconcile the observed population health patterns. Rising white mortality in the United States is not explained by traditional social and economic population health indicators, but instead by a perceived decline in relative group status on the part of whites - despite no actual loss in relative group position.

This article draws on the vast evidence that suggests, on one hand, that socioeconomic inequalities in health are present in every society in which they have been measured and, on the other hand, that the size of inequalities varies substantially across societies. We conduct a comparative case study of the United States and Canada to explore the role of neoliberalism as a force that has created inequalities in socioeconomic resources (and thus in health) in both societies and the roles of other societal forces (political, economic, and social) that have provided a buffer, thereby lessening socioeconomic inequalities or their effects on health. Our findings suggest that, from 1980 to 2008, while both the United States and Canada underwent significant neoliberal reforms, Canada showed more resilience in terms of health inequalities as a result of differences in: ( a) the degree of income inequality, itself resulting from differences in features of the labor market and tax and transfer policies, ( b) equality in the provision of social goods such as health care and education, and ( c) the extent of social cohesiveness across race/ethnic- and class-based groups. Our study suggests that further attention must be given to both causes and buffers of health inequalities.