Primary care in the US faces persistent workforce shortages compounded by concerns about retention, with increasing numbers of physicians exiting the workforce in recent years. Non-US international medical graduates (IMGs) represent a substantial share of the residency pathway in specialties that provide first-contact care and chronic disease management. Most IMGs enter US graduate medical education through J-1 visas, which are specifically designed for clinical training and typically require return to the home country upon completion of training. In contrast, H-1B visas are employment-based and allow physicians to remain in the US for clinical practice, making them an important pathway for workforce retention. Policy changes affecting H-1B visa availability may have important implications for the stability of the training pathway.5 This study quantifies specialty- and state-level reliance on non-US IMGs in primary care training and estimates the extent to which H-1B visa restrictions could disrupt this pathway.

President Donald Trump has made lowering prescription drug prices a signature issue during both his administrations. Until recently, however, he had relatively little to show for it. During his first term, Congress did not enact major drug-pricing legislation, and his executive initiatives on drug importation, international reference pricing in Medicare Part B, and rebate reform in Medicare Part D were left unimplemented.

The second Trump administration has pursued a broader, more aggressive “most-favored-nation” (MFN) drug pricing agenda, seeking to peg US prices to international benchmarks and thereby import lower prices paid abroad. Its initiatives include the Global Benchmark for Efficient Drug Pricing (GLOBE) model and the Guarding US Medicare Against Rising Drug Costs (GUARD) model, mandatory MFN reference pricing models for Medicare Parts B and D, respectively; and the GENErating cost Reductions fOr US Medicaid (GENEROUS) model, a voluntary model for Medicaid.

Most public attention, however, has focused on voluntary bilateral agreements with 17 drug companies representing 86 percent of branded drug sales. Announced between September 2025 and April 2026, these agreements include price concessions, commitments to sell drugs through direct-to-consumer channels (such as the administration’s TrumpRx website), and investments in domestic drug development and manufacturing (exhibit 1).

The significance of these deals is disputed. The White House touts them as “the most significant actions ever taken” to lower drug prices. Critics, such as Senator Ron Wyden (D-OR), have called them “a sham that benefits pharmaceutical corporations while offering little to no savings to patients and their families.”

We examine the existence of altruism budgets (AB), which imply fixed monetary allocations to prosocial behaviours (PSB), and benevolence constraints (BC), which refer to wider limits to benevolent behaviour, giving rise to a substitution between PSB's across domains and causes, including volunteering and biological donations. Using longitudinal data from the Netherlands from 2003 to 2019, we exploit two exogenous shocks to charitable behaviour: the introduction of a tax incentive that increased donations to culture and the arts, and a large-scale emergency fundraising campaign targeting Syrian refugees and victims of Typhoon Haiyan. Our results provide no evidence of AB but robust evidence of BC. We find a robust and precisely estimated decline in volunteering of approximately 4.5 hours per month after the emergency aid campaign among donors. This pattern suggests that individuals substitute across different forms of prosocial behaviour, reallocating effort from non-monetary activities such as volunteering toward monetary contributions during periods of heightened charitable demand.