American Planning Research Articles

A Medical Student-Inspired Advocacy Effort to Improve Pediatric Mental Health Services

The demand for pediatric mental health services has exceeded the supply of mental health providers for decades and increased significantly during the COVID-19 pandemic. Given the federal administration’s interest in passing a major funding bill to address the COVID-19 pandemic, the authors recognized an opportunity to collaborate in an advocacy effort to request federal financial support for Pediatric Mental Health Care Access Programs (PMHCAPs). The challenges of the pandemic and limited travel became assets as the advocacy team, who lived hundreds of miles apart in 2 states, met virtually with each other and with Congressional staff during February of 2021 on a tight timeline. In March of 2021, President Biden signed the American Rescue Plan that provided $80 million for PMHCAPs.

Automating benefits delivery: lowering health insurance costs for unemployment insurance recipients.

To provide financial relief to those affected by the COVID-19 pandemic, from July to December 2021, the American Rescue Plan Act temporarily expanded eligibility for cost-sharing reduction (CSR) silver 94 plans that cover 94% of medical costs for unemployment insurance (UI) recipients enrolled in the Affordable Care Act (ACA) Marketplaces. In June 2021, California's ACA Marketplace automatically redetermined eligibility and enrollment for 79 645 UI recipients so the enhanced subsidies would be applied without any action required among program participants. Using administrative data from California and a difference-in-differences design, we found that enrollees automatically moved to CSR silver 94 plans for the second half of 2021 saved $295 in premiums and $180 in out-of-pocket expenses (or $475 in total). These findings can inform state and federal policymakers exploring ways of automating benefits delivery for consumers already engaging with other safety-net programs to increase health insurance affordability.

Health Plan Switching and Health Care Utilization

While the Patient Protection and Affordable Care Act (ACA) helped make health insurance premiums more affordable with premium tax credits, ACA marketplace enrollees continue to face barriers to care. To investigate the effect of informational emails on plan switching and health care utilization. This randomized clinical trial was conducted during the 2021 special enrollment period in California's Affordable Care Act marketplace among households that reported receiving unemployment insurance and were enrolled in non-silver-tier plans. The trial targeted 42 470 households that became temporarily eligible for cost-sharing reduction (CSR) silver plans that covered 94% of medical costs (CSR silver 94 plans) as a result of the 2021 American Rescue Plan Act. Households were randomized to either a no-email control group or to a treatment group receiving 2 informational emails encouraging households to switch to CSR plans. The primary outcome was the switch rate to a CSR silver plan by July 31, 2021. Secondary outcomes include various measures of health care utilization in the second half of 2021 (July 1, 2021, to December 31, 2021). Health care utilization was measured by rates of practitioner visits, emergency department visits, hospitalizations, and prescription fills. Of the 42 470 households (head of household mean [SD], age, 41.4 [13.3] years; 51.7% male), 10 650 (25.1%) were in the control group and 31 820 (74.9%) were in the treatment group. The emails led to a statistically significant 3.1-percentage point (95% CI, 2.6-3.6 percentage points) increase in CSR silver 94 enrollment (a 74.8% relative increase) by July 31, 2021, and a 1.3-percentage point (95% CI, 0.2-2.4 percentage points) increase (a 2.3% relative increase) in practitioner visits by December 31, 2021. The emails had no detectable effect on prescription fills, emergency department visits, or hospitalizations. The results of this randomized clinical trial provide experimental evidence that, with access to more affordable health care, individuals are more likely to visit practitioners. ClinicalTrials.gov Identifier: NCT05891418.

Local Governments, Pandemic Aid, and Community Violence Intervention

Expenditures on police departments account for significant portions of local government budgets in the United States. Yet activism on police reform and changing views on the causes of violence have called into question law enforcement's role in public safety. While intergovernmental transfers have historically supported traditional policing, the American Rescue Plan Act's Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) affords cities the opportunity to disrupt the status quo by providing them with the federal funds and flexibility to reshape their public safety policies around Community Violence Interventions (CVIs). This article examines how 13 cities that participated in a White House convened collaborative used CSLFRF aid to support CVIs. Our analysis reveals significant variation in how these cities in allocated CSLFRF dollars to CVI programs, suggesting that the combination of federal aid and White House encouragement has thus far led to incremental policy changes, whose durability remains an open question.

Addressing infection prevention and control in Alabama through the long-term care strike team.

The COVID-19 pandemic exposed the lack of infection prevention and control (IPC) infrastructure among long-term care facilities (LTCFs) in the United States; the situation in Alabama is particularly dire with LTCFs receiving some of the lowest quality ratings in the country. Alabama's LTCFs continue to be challenged by frequent staff turnover, vaccine hesitancy, and reluctance to embrace new Centers for Disease Control and Prevention (CDC) recommendations such as enhanced barrier precautions. However, the American Rescue Plan of 2021 made funds available to states through a CDC Epidemiology and Laboratory (ELC) Cooperative Agreement to promote IPC system improvement, including the creation of the Alabama Nursing Home and Long-Term Care Strike Team (LTC Strike Team). In this article, we reviewed preliminary data from Alabama for the first year of the 2-year cooperative agreement cycle (2022--2023). Data included activity tracking by Infection Preventionists (IPs) and evaluations submitted voluntarily by LTCFs upon completion of trainings and/or direct services provided by the LTC Strike Team. Results indicated a significant need for IPC training among LTCFs and a high level of satisfaction with the services provided by IPs. Despite successes, it is unclear if future funding will be available to support long-term sustainability efforts.

Consumption responses to an unconditional child allowance in the United States

The COVID-19 pandemic put families in the United States under financial stress. The federal government’s largest response in 2021 was the American Rescue Plan Act, which temporarily expanded the Child Tax Credit (CTC) into a large, unconditional child allowance providing monthly payments to families with children. This study investigates consumption responses to the CTC expansion using anonymized mobile-location data and debit/credit card data that track visits and spending at 1.3 million establishments across US counties. For identification, we exploit variation in the size of households’ income gains due to the CTC across counties in a difference-in-differences framework spanning January 2021 to May 2022. Counties benefiting most from the CTC expansion experienced larger increases in visits to childcare centres and health- and personal-care establishments, and increased visits to and spending per transaction at grocery and general stores. These findings suggest that the CTC expansion increased household consumption and spending on children.

Proceed with caution: US local governments and the American Rescue Plan

ABSTRACT Will a legacy of fiscal stress limit local governments’ willingness to make equity-focused investments even in the context of the relative surplus that American Rescue Plan funds provide for local governments in the US after COVID-19? Focus groups with local officials show the desire to address basic infrastructure investments (water and sewer) is primary, and concerns over recurring expenditure responsibilities, administrative burden and rising citizen expectations cause them to proceed with caution. However, the flexibility and size of ARPA funds make more progressive investments possible.

Characterizing home care services use among US survivors of cancer.

90 Background: Cancer survivors often require home care services, but accessibility barriers prevent many patients and care partners from harnessing their full benefit. We sought to characterize home care services use among cancer survivors in the United States. Methods: We identified patients with and without history of cancer from 2016 to 2019 in the nationally representative Medical Expenditure Panel Survey (MEPS). We extracted sociodemographics and clinical characteristics. We constructed a composite measure of patients being eligible for home care if they reported any one of three criteria: completely unable to do any activity, limitations doing housework, or dependent on activities of daily living. We identified home care use and associated details, including type of home care provided—by licensed professionals (e.g., home health nurse, physical therapy etc.) associated with agencies, hospitals, or nursing homes, by non-agency (self-employed persons), and by unpaid informal care providers not living with the patient, and the number of days such services were provided in a calendar year. We used multivariable logistic regression to identify factors associated with eligibility for and non-receipt of home care services. Results: We identified 9,585 cancer survivors (median age, 67 years, 53% female, 76% non-Hispanic White, 15% breast cancer) and 83,393 persons without cancer history. Cancer survivors were more often eligible for (22% vs 9%) and more often used home care (10% vs 3%), compared to those without cancer. Cancer survivors receiving home care annually remained stable from 2016-2019 (10%, 8%, 11%, 12%; p = 0.25). Among cancer survivors who received home care, the annual median/mean days of services were 28/87 days. Of these, the median/mean days of service were: agency (16/66), non-agency (0/4), and unpaid informal caregivers (0/17). In multivariable analysis, higher age (per year, aOR 1.02), female sex (aOR 1.29), income below poverty (aOR 1.82), unmarried status (aOR 1.65), public insurance (aOR 2.15), and number of comorbidities (per 1 comorbidity, aOR 1.70), had increased odds for being eligible for home care (p <0.05 for all). In multivariable analysis, higher age (per year, aOR 1.01), unmarried status (aOR 1.55), and number of comorbidities (per 1 comorbidity, aOR 1.58) had higher odds, while Hispanic ethnicity was associated with lower odds of receiving home care (p <0.05 for all). Conclusions: In this nationally representative study, we found that only 10% of US cancer survivors received home care services, with notable sociodemographic variability. Our data highlight an urgent need to understand underlying market factors, and whether these data reflect a capacity, incentive, or implementation problem. Policy level efforts from the recent American Rescue Plan Act and upcoming Cancer Moonshot initiatives should aim to fund home-based care programs.

The Potential Long-Run Impact of a Permanently Expanded Child Tax Credit

Inclusion of the expanded Child Tax Credit (CTC) in the 2021 American Rescue Plan was, for many, a feasibility test of the impact of a permanent child allowance in the U.S. The CTC expansion was short-lived, however, so evaluations of its effects cannot provide complete evidence on the long-run impacts of a permanent expansion of the benefit. Here, we predict the long-term effects of a permanently expanded, refundable CTC. We use theory from standard economic models, frameworks from behavioral science and child development, and empirical evidence from literature that has evaluated previous long-term cash and quasi-cash transfers to families with children. We find that provision of the benefit would lead to increased future adult earnings and tax payments; improved child health and longevity; and reduced costs in health care, crime, and child protection. We predict that benefits to society would outweigh costs nearly 10 to 1, with most benefits due to the tax credit’s refundability.

Mitigating urban light pollution: A review of municipal regulations and implications for planners

ABSTRACT Propelled by more energy-efficient technologies such as light-emitting diodes, the growth of outdoor light at night is raising concerns about light pollution (LP). Given mounting evidence of LP’s risks to human wellbeing, nature and wildlife, and views of the dark sky, this paper examines the extent to which LP concerns are addressed in land use plans, policies, and regulations in nine U.S. cities, including Flagstaff, Arizona, a city known for its model lighting code. Through a review of zoning and other ordinances, area and sectoral plans and policies, media reports, and interviews with planners, this study documents that LP has yet to be taken seriously in municipal codes of most study cities. Drawing from the Flagstaff model, it offers recommendations for evidence-based, objective standards for three key dimensions of LP-mitigation: limiting total illumination or lumens per acre, shielding of lamps, and specifying luminaire characteristics. ABBREVIATIONS AMA: American Medical Association; APA: American Planning Association; CCT: Correlated Color Temperature; CRI: Color Rendition Index; ESCO: Energy Service Companies; f.c.: foot candle; HPS: High-Pressure Sodium; IDA: International Dark-Sky Association; LED: Light-Emitting Diode; LP: Light Pollution; LPS: Low-Pressure Sodium; LZ: Lighting Zone; NSA: Narrow-Spectrum Amber

Detect and Engage: A New American Way of War

The threat that paces American force planning is not from Russia, but rather from China. This is leading to a new way of warfare. The authors call it ‘detect and engage’. The confluence of artificial intelligence, applied quantum mechanics and satellite networking permits dispersed and diverse units and platforms to operate as a unified joint force across sea, air, land and space. Cyber operations, practically indifferent to location, further enable the United States to reduce reliance on geographically concentrated and exposed forces. Advanced technology is just one step in operationalising new forms of warfare. Others include anticipating adversary responses; building robust inventories of extended-range weapons; knowing when and how to conduct close-in operations; integrating and empowering defence allies; and maintaining US forward presence. Harnessing leading-edge technology to improve global US military effectiveness reflects neither an isolationist nor an insular policy, but rather one of ongoing engagement.

Impact of the expanded child tax credit and its expiration on adult psychological well-being

The COVID-19 pandemic has exacerbated stress and psychological distress among adults with children, with certain populations experiencing a greater mental health burden. The expanded Child Tax Credit (CTC) under the 2021 American Rescue Plan Act provided temporary relief to families with children through monthly payments from July through December 2021, offering a unique opportunity to examine the impact of a near-universal cash transfer on adult psychological well-being in the United States. We use the Household Pulse Survey Waves 28–41 (April 14, 2021 to January 10, 2022) to analyze the CTC expansion and Waves 34–42 (July 21, 2021 to February 7, 2022) to examine the expiration of the expanded CTC to investigate the effects of the expanded CTC and its expiration on psychological distress of adults in households with children and its differential effects by gender, education, marital status, and race and ethnicity (N = 167,772). We employ a difference-in-difference methodology by leveraging the policy-induced variation in the additional credits that households are eligible for. Our results indicate that the expanded CTC led to a significant reduction in the percentage of having at least mild symptoms of psychological distress in the overall sample, especially among female, single, married, and Hispanic adults. No significant effects were found on the rate of moderate or severe psychological distress symptoms, suggesting that more severe forms of psychological distress may require more comprehensive and long-term interventions. We find that more adults experienced moderate to severe psychological distress after the monthly CTC payments ended. We discuss the role of the expanded CTC in buffering mental health crises during the pandemic and the implications of the heterogeneous policy effects by subgroups.

Confederal Union and Empire: Placing the Albany Plan (1754) in Imperial Context

AbstractWhy did British politicians on both sides of the Atlantic propose a confederal rather than incorporating union in 1754? This question has been difficult to answer because most scholars have focused on the Albany Plan of Union outside of its imperial context, seeing in the plan either evidence of nascent American nationalism, a point of divergence between American and British conceptions of empire, or a missed moment to establish parliamentary supremacy over America. I show instead that the British and American plans for confederal union in 1754 formed part of an intensely partisan and pan-imperial debate about the nature of the British imperial constitution. The failure to adopt a confederal imperial constitution in 1754 had more to do with the contingency of the outbreak of the Seven Years’ War than with diverging British and American visions of empire or nascent American nationalism.

Politics and the Public Health Workforce: Lessons Suggested from a Five-State Study.

The COVID-19 pandemic exposed the shortcomings of the United States public health system. High on the list is a public health workforce that is understaffed, underpaid, and undervalued. To rebuild that workforce, the American Rescue Plan (ARP) appropriated $7.66 billion to help create 100,000 new public health jobs. As part of this initiative, the Centers for Disease Control and Prevention (CDC) distributed roughly $2 billion to state, local, tribal, and territorial health agencies for use between July 1, 2021, and June 30, 2023. At the same time, several states have enacted (or are considering enacting) initiatives to increase state funding for their local health departments with the goal of ensuring that these departments can deliver a core set of services to all residents. The differences in approach between this first round of ARP funding and theseparate state initiatives offer an opportunity to compare, contrast, and suggest lessons learned. After interviewing leaders at the CDC and other experts on the nation's public health workforce, we visited five states (Kentucky, Indiana, Mississippi, New York, and Washington) to examine, by means of interviews and documents, the implementation and impact of both the ARP workforce funds as well as the state-based initiatives. Three themes emerged. First, states are not spending the CDC workforce funding in a timely fashion; although the specifics vary, there are several organizational, political, and bureaucratic obstacles. Second, the state-based initiatives follow different political paths but rely on the same overarching strategy: gain the support of local elected officials by providing funding directly to local health departments, albeit with performance strings attached. These state initiatives offer their federal counterparts a political roadmap toward a more robust model of public health funding. Third, even with increased funding, we will not meet the nation's public health workforce challenges until we make public health a more attractive career path (with higher pay, improved working conditions, and more training and promotion opportunities) with fewer bureaucratic barriers to entry (most importantly, with less reliance on outdated civil service rules). The politics of public health requires a closer look at the role played by county commissioners, mayors, and other local elected officials. We need a political strategy to persuade these officials that their constituents will benefit from a better public health system.

Thinking Sideways: A Plea for “Weak Theory”

This essay examines the implications of interdisciplinary debates on the power of “weak theory” for planning practice. Focusing on the North American planning context, I argue that the concept of “weak theory” – with its emphasis on specificity and mid-level generalizations and its openness to doubt and contingency – has long been a source of discussion about social interventions, but the significance of this approach for understanding cities and informing city planning practice remains largely unappreciated. This essay critically reflects on the concept of “weak theory” and examines how it can promote intellectual diversity and enhance planning practice by making theory less dogmatic and more accessible.

Collateral Damages: Landlords and the Urban Housing Crisis

"Collateral Damages: Landlords and the Urban Housing Crisis." Journal of the American Planning Association, ahead-of-print(ahead-of-print), p. 1

Finding Mutual Benefit in Urban Development

Problem, research strategy, and findings Public and nonprofit agencies struggle to compete for space in cities as development pressures and unaffordability intensify. We have identified a potential solution in creative mixed-use projects: ad hoc, cross-sectoral partnerships to develop mixed-use buildings involving a public or nonprofit use. We built our analysis on a census of 54 projects in Toronto (Canada), interviews with 24 stakeholders, and a rich data set of secondary sources. We traced the emergence of this approach in Toronto over 2 decades, mapping its geographical expansion, stakeholder diversification, and the various mutually beneficial spatial arrangements of buildings. Building on the theory of collaborative advantage, we analyzed the motivations behind cross-sector partnered ventures, finding a gradual shift from resorting to partnership in reaction to obstacles to partnerships strategically designed to pool together land, resources, and support for development. Third, we highlight here the role of champions in underwriting risks and the limits of relying on market solutions for social purposes. We conclude by discussing the relevance of collaborative city-building in land-constrained North American planning contexts. Takeaway for practice Government agencies, nonprofit organizations, and developers alike can benefit from creative mixed-use partnerships, which unlock access to land, resources, development capacities, and community support. Contrary to popular perceptions, intentional separation of nonprofit and for-profit uses can be mutually beneficial. Despite the one-off nature of creative mixed-use development, it can be propelled by an initial cohort of successful partnerships and landmark projects. Limited-time leases, insufficient organizational capacity, and low market demand hinder its implementation.

Adapting the Voicing My CHOiCES Advance Care Planning Communication Guide for Australian Adolescents and Young Adults with Cancer: Appropriateness, Acceptability, and Considerations for Clinical Practice.

Background: Adolescents and young adults (AYAs) with life-threatening illnesses need support to discuss and voice their end-of-life choices. Voicing My CHOiCES (VMC) is a research-informed American advanced care planning guide designed to help facilitate these difficult discussions. This multi-perspective study aimed to evaluate its appropriateness, acceptability, and clinical considerations for Australian AYAs with cancer. Procedure: Forty-three participants including AYAs who were either undergoing or recently completed cancer treatment, their parents, and multidisciplinary health professionals assessed the acceptability of each VMC section quantitatively (appropriateness-yes/no, helpfulness and whether content caused stress-1 = not at all, to 5 = very) and qualitatively (sources of stress). AYAs also assessed the benefit and burden of completing several sections of the document, to inform clinical considerations. We conducted a mixed-methods analysis to obtain descriptive statistics and to identify prominent themes. Results: In terms of acceptability, almost all participants (96%) rated VMC as appropriate overall. Perceived helpfulness to their situation (to themselves/their child/their patients), to others, and stressfulness were rated, on average, as 4.1, 4.0, and 2.7/5, respectively. Stress was attributed to individual and personal factors, as well as interpersonal worries. All sections were considered more beneficial than burdensome, except for the Spiritual Thoughts section (Section 6). Conclusions: While VMC is an acceptable advance care planning guide for AYAs with cancer, changes to the guide were suggested for the Australian context. Health professionals implementing VMC will need to address and mitigate anticipated sources of stress identified here. Future research evaluating the impact of a new culturally adapted Australian VMC guide is an important next step. Finally, the clinical implications of the present study are suggested.

Pacific Fleet to Singapore?: Deterrence, Warfighting, and Anglo-American Planning for the Defense of Southeast Asia, 1937-1941

ABSTRACT For the 20 years before the outbreak of the Pacific War, Great Britain based its grand strategy in the Far East around the presence – and potential – of the Singapore Naval Base. The Americans, for a time, agreed in the project’s potential in the face of increasing Japanese belligerence. This analysis examines the place of the Singapore Naval Base in Anglo-American planning for the defence of Southeast Asia. It focuses on British efforts to lobby the Americans to deploy the Pacific Fleet to Singapore to deter Japan, the evolution of American plans for the defence of the Far East, and how all these interacted. It argues that the British desire to use the Pacific Fleet as a deterrent force based at Singapore, and the American assessments of how the Pacific Fleet would actually fight Japan from Singapore, represented a conceptual disconnect they could not overcome until faced with imminent hostilities. Scrutinizing the discussions and plans related to this understudied episode provides additional understanding not only how the aspirant allies viewed the growing threat from Japan, but also how they viewed each other.

A Brief History of Motion: From the Wheel, to the Car, to What Comes Next

"A Brief History of Motion: From the Wheel, to the Car, to What Comes Next." Journal of the American Planning Association, ahead-of-print(ahead-of-print), p. 1