Question: How did obstetric-related Emergency Medical Treatment and Labor Act (EMTALA) violations change in association with state-level abortion policy?

Findings: In this difference-in-differences analysis of EMTALA violations from 2018 to the first quarter of 2023, states with no health exceptions saw a substantial rise in obstetric-related violations that were associated with policies adopted by Texas. There was a concurrent rise in emergency department utilization, and screening failures suggest that violations may have increasingly occurred on arrival before treatment.

Meaning: The study results suggest that state abortion laws may undermine federally protected care in obstetric emergencies.

Medicare is often regarded as a universal benefit for most US citizens and legal permanent residents. The program is financed through payroll tax contributions during individuals’ working lives with the expectation of coverage at age 65 years for most people. However, those who die prematurely are unable to realize the benefits they helped fund—raising equity concerns for populations with lower life expectancies.

In 2022, the mean life expectancy in the US was 77.5 years, down from 78.9 years in 2014,2 partly due to rising mortality among working-age adults and widening disparities across racial and socioeconomic groups.3-5 As health declines begin earlier—especially for Black individuals—a growing number may not reach Medicare eligibility. This inequity in unrealized Medicare benefits underscores the need to understand how premature mortality before age 65 years has varied over time and by race.

Federal health spending plays a central role in the nation’s long-term fiscal outlook. In 2024, Medicare, Medicaid, and the Children’s Health Insurance Program accounted for 31 percent of all federal program spending—$1.8 trillion—and this total is projected to rise significantly over the next 30 years. At the same time, private health insurance spending per enrollee is expected to grow by over 50 percent by 2032. These unsustainable trends—occurring without commensurate improvements in population health— create a burning need for reform: Without meaningful change, rising health care costs will increasingly strain household budgets, crowd out other federal and state priorities, and undermine the nation’s long-term fiscal stability.

Against this urgent backdrop, the United States Government Accountability Office issued its 2024 report, “Highlights of a Forum: Reducing Spending and Enhancing Value in the U.S. Health Care System”. The report summarizes the discussions of an expert forum convened in October 2024. The forum brought together participants from government, academia, and industry to explore persistent challenges in United States (US) health care spending and identify opportunities to improve value. The report’s recommendations were structured around five pre-identified areas of potential reform: strengthening primary care; expanding the health care workforce; reforming pricing to better align with high value care; revising Medicare physician payments; and mitigating anticompetitive actions and practices. As two of the forum participants, we highlight below the areas we believe are most critical for policymakers to consider and offer new insights that have gained salience given shifts in the policy landscape since the forum was conducted.

Introduction: By 2050, antimicrobial resistance (AMR) could lead to over 10 million deaths annually and $100 trillion in healthcare costs, making it one of the most urgent public health threats. The WHO recommends AMR National Action Plans (AMR NAPs) to address this threat, but the effectiveness of these plans is unknown.

Methods: We estimate the impact of AMR NAPs on retail sales of all antibiotics across 68 countries from 2014 to 2023 using IQVIAs Multinational Integrated Data Analysis System dataset. We further examine the effect of AMR NAP adoption on the proportion of antibiotic sales by WHO AWaRe (Access, Watch, Reserve) classification. To account for differences in the quality of the AMR NAP, we also examine if countries with a better NAP have differential use of antibiotics following its adoption. Finally, we explore whether countries with higher quality NAPs make differential use of azithromycin during the COVID-19 pandemic.

Results: The adoption of an AMR NAP did not have a significant impact on total retail antibiotic sales. But when accounting for the quality of the AMR NAP, as identified from an evaluation of NAP plans, we find that high-scoring AMR NAPs significantly increased the proportion of retail sales from Access-class agents (0.031; 95% CI 0.003 to 0.06), and significantly decreased the proportion of Watch-class antibiotics (−0.03; 95% CI −0.055 to −0.005) as compared with those with lower scoring or no NAPs. Countries with high-scoring NAPs also exhibited lower retail azithromycin sales per 1000 persons during the COVID-19 pandemic (−49.08; 95% CI −89 to −9.16).

Conclusions: Countries with higher quality AMR NAPs exhibit more appropriate use of essential antibiotics overall and less inappropriate utilisation of azithromycin during the COVID-19 pandemic compared with those with no or low-scoring plans. Well-developed AMR NAPs may be a useful policy tool to promote more judicious antibiotic use globally.

Life expectancy in the USA is considerably lower than in most high-income countries, with many deaths considered preventable. The extent by which poor performance on prevention measures and public health policies in the USA could be contributing to this issue is not well understood. To address this issue, we compared publicly available population-based indicators of health care across different levels of prevention in the USA and six high-income countries (ie, Australia, Canada, Germany, France, Sweden, and the UK) and Organisation for Economic Co-operation and Development countries between 2010 and 2023. Relative to comparator countries, the USA had a younger population and lower smoking rates, but it had higher obesity prevalence, calorie intake, illicit drug use, and gun and vehicle ownership. Regarding public health policies that lie largely outside the health-care system, the USA compared unfavourably to comparator countries. For measures dependent on the health-care system, the USA performed well across several measures of clinical prevention, including screening rates and diagnosis and control of chronic conditions. However, the USA was worse on measures of access to health care and coverage. While the USA performs well in prevention efforts within the health-care system compared with other countries for people with access to the system, it faces greater risk from external factors, generally worse dietary intake, and implements weaker public health prevention and regulation against harmful products that might exacerbate these issues. To improve population health, policy makers should prioritise multi-sectoral investments in prevention policies and improve access to health care.

The Inflation Reduction Act (IRA) requires Medicare to negotiate prices for certain brand-name drugs with gross annual Medicare spending exceeding $200 million. Small-molecule drugs are exempt from negotiation for 9 years following US Food and Drug Administration approval and biologics for 13 years. The pharmaceutical industry, some members of Congress, and the Trump administration have argued that this difference prioritizes the development of biologics over small-molecule drugs and have proposed aligning the initial eligibility periods for both at 13 years.1,2 To inform these policy discussions, we compared the revenues earned by manufacturers after 9 vs 13 years on negotiation-eligible products from 2012 to 2022.

The COVID-19 pandemic has underscored the importance of resilient health systems that can manage and adapt to large-scale health crises. However, the relationship between resilience and health system performance remains unclear. While some view performance as a feature of resilience, others conflate the two. Excess mortality—defined as the difference between observed and expected deaths during a given period—is often used to assess resilience, but may introduce bias. In particular, countries with stronger pre-pandemic performance and lower baseline mortality may appear to have worse resilience simply because they had less “room” for mortality to rise under normal conditions.

Trade-related tensions between the United States and China have escalated dramatically in recent months. Despite a tentative agreement in May 2025 (extended in August 2025) to reduce the size of newly imposed tariffs on both sides, geopolitical frictions remain. Among other implications, these tensions threaten the cross-border trade of medicines. China has long been a major global supplier of generic drugs and active pharmaceutical ingredients. In recent years, it has also emerged as an important player in new drug development — a field traditionally dominated by the United States and European countries. This shift has implications for global access to promising new medicines and presents challenges for U.S. regulators and policymakers.

More than 75% of cancer drugs are approved by the US Food and Drug Administration (FDA) through expedited regulatory programs,(1) the use of which often leaves clinical uncertainties that may arise from issues related to trial design, conduct, analysis, or reporting—such as unvalidated end points, limited long-term data, or approval based on a single trial—about drug efficacy and safety.(2) Communicating these uncertainties is important, as clinicians may otherwise be unaware and overestimate a drug’s benefits and underestimate its risks.(3)

Although the FDA describes these uncertainties in detail in its benefit-risk assessments,(2) these documents are not widely read by clinicians. Instead, clinicians often rely on journal publications and guidelines. It is unclear whether clinical trial uncertainties about newly approved cancer drugs are reported in these sources.

Health systems globally face growing challenges, including ageing populations, increasing prevalence of chronic diseases, and limited resources to fund advances in health care. Emerging issues, such as climate change, infectious disease outbreaks, large-scale migration, and geopolitical instability, are placing additional strain on already burdened health systems. In Greece, many of these stressors have converged in the past 15 years, exposing structural vulnerabilities and testing health system resilience.(1–3)

Against this backdrop, Greece has implemented a series of reforms to improve service delivery and address public health challenges, but their long-term sustainability remains uncertain. The COVID-19 pandemic offered an illustrative example; the initial response was effective and driven by the prompt adoption of public health measures and interministerial coordination. However, as the pandemic progressed, persistent weaknesses and underdeveloped public health infrastructure exposed crucial vulnerabilities, ultimately undermining the health system's capacity to sustain an effective response.(4) Examining the Greek health system's adaptive capacity more broadly offers important insights for policy makers, in Greece and in other contexts facing comparable structural and fiscal constraints.

This Health Policy paper explores the key and emerging public health and health system challenges in Greece. The paper also provides an overview of recent reform efforts, identifying crucial gaps and opportunities for strengthening the health system to ensure its long-term sustainability.

People with schizophrenia are at heightened risk for physical multimorbidity and premature death. Semaglutide improves cardiometabolic outcomes, yet research is limited among individuals with schizophrenia. This study explored weight loss in Veterans with schizophrenia and physical multimorbidity (ie, heart failure and diabetes) prescribed semaglutide and compared weight changes to those in Veterans without schizophrenia. We hypothesized that those with schizophrenia would experience less weight loss compared to those without schizophrenia.

Competition between firms selling similar drugs is often fostered by policymakers as a means to curb pharmaceutical spending. While firms may compete within these specific drug markets, they also repeatedly encounter rival firms in different markets. This may shape competitive dynamics within and between markets. Yet, multimarket contacts, particularly relevant for multiproduct firms such as pharmaceutical companies, are often overlooked by pricing regulations. This paper investigates how multimarket contacts influence competition between pharmaceutical firms in off-patent markets. Using detailed product-level information on all retail pharmacy sales of generic statin drugs, we quantify the universe of multimarket contacts between firms in these off-patent markets, in Portugal, between 2015 and 2017. We then assess how multimarket contacts affect price competition. To do so, we explore the strict price regulation in Portuguese generic drug markets. Specifically, the Portuguese Internal Reference Pricing System (RPS) defines a price cap for each generic drug. Rather than examining absolute drug prices, we quantify the degree of price competition as the ratio between a firm's drug price and its regulatory price cap (price-to-cap ratio). We find that firms with more multimarket interactions set prices closer to price caps, consistent with the mutual forbearance hypothesis. This effect persists after controlling for brand status, lagged market share, and is not explained by common ownership. Our main results are consistent across alternative model specifications. However, due to limited within-firm variation over time, the effect is not significant in system generalized method of moment instrumental variable estimates. These results suggest that price caps may act as coordination anchors, thus lowering price competition between firms. Policymakers should consider targeted price cap adjustments as safeguards to preserve competition in off-patent drug markets.

Equitable access to essential medicines, which the World Health Organization (WHO) defines as those that meet the priority needs of the population,1 is key to achieving universal health care coverage.(2) However, it is estimated that essential medicines are unaffordable or unavailable to 1 in 4 people worldwide.(3) As governments strive to achieve universal access to essential medicines, it is important to understand how the prices and affordability of these medicines vary between countries. High drug prices strain both personal and government budgets, especially in low- and middle-income countries, where patients often face high out-of-pocket costs.

Although many national surveys of medicine prices and affordability have been conducted, fewer analyses have compared these variables internationally, with most research dating back to 2011 or earlier.(4-20) Many of these studies have focused on high-income countries. Of the studies that also included low- and middle-income nations, most compared the prices of 15 or fewer medicines or included a small number of countries, limiting the generalizability of those findings. Therefore, little is known about the relationship between national income and drug prices. The question remains whether some poor countries routinely pay more than rich countries for the same prescription drugs, possibly owing to weaker pharmaceutical pricing policies.

This cross-sectional study used global data on pharmaceutical sales to compare the list prices of 549 essential medicines in 72 high-, middle-, and low-income markets (covering 87 countries) in 2022, both in nominal and purchasing power–adjusted terms. We also evaluated the affordability of 8 essential medicines used to treat major causes of death and disability globally.

On May 12, 2025, the Trump administration issued an executive order to lower prescription drug costs by mandating that the US pay no more than prices in peer countries. The legality of implementing this so-called most favored nation (MFN) pricing through executive action is unclear. However, the idea of benchmarking US drug prices to prices in other countries is not new. The Trump administration unsuccessfully attempted a more limited MFN policy during its first term, and a 2019 bill passed by House Democrats used international prices as upper limits for Medicare price negotiations. Although lowering drug prices is a priority, achieving this by linking prices in the US to those in other countries is a misguided approach built on a misdiagnosis of the reason prices are higher in the US than in other countries.

The responses to our study on wealth and mortality in the United States and Europe raise important questions about causal inference, potential confounding, and the interpretation of cross-national differences. As noted by the correspondents, our findings reflect associations, not causal relationships. Although the patterns we observed were consistent across settings, more work is needed to disentangle the complex relationship between wealth and health.

Uncertainties about the benefits and harms of new drugs are common at the time of drugs’ approval. It is unclear to what extent the Food and Drug Administration (FDA) communicates these uncertainties in the FDA-approved prescribing information (the drug label), which is the primary channel of communication between the FDA and physicians. Although physicians might not regularly consult the drug label for prescribing decisions, other information sources used by physicians either index or incorporate information from the label. We searched FDA review documents for uncertainties identified by FDA reviewers with new cancer drugs. We considered the subset of uncertainties highlighted in the FDA’s Benefit-Risk Framework as important to the FDA’s approval decision. During the period 2019–22, the FDA approved fifty-two new cancer drugs. In review documents, FDA reviewers identified a total of 213 clinical trial uncertainties with new cancer drugs, 50 percent of which were considered to be important uncertainties to the FDA’s approval decision. Labels for physicians reported information on 26 percent of all uncertainties and 48 percent of uncertainties that were important to the FDA’s approval decision. Communicating uncertainties about the evidence of drugs in the label is essential for informing physicians about drugs’ safe and effective use.

Scholars express concern that general practitioner shortages and specialist surpluses induce overspecialization, with overuse of costly specialist services and underuse of cost-effective primary care services. Yet few studies directly assess the relationship between physician supply and patient utilization. Given this gap, this paper examines the associations between physician supply, care utilization, and patient need and whether patients use more specialists in areas with lower primary care supply.

We appreciate the responses to our Article, which suggest that the health cost of paying for new pharmaceuticals in the National Health Service (NHS), estimated at £1·25 million quality-adjusted life-years (QALYs) lost between 2000 and 2020, might be justified by the benefits of incentivising future innovation, attracting industry funding, or prioritising certain populations—we disagree.

Outcomes after a hip repair in the older adult population are highly dependent on patients’ characteristics. However, contextual factors such as the hospital of treatment may have an impact not sufficiently studied. We aimed to elicit the effect of hospital providers on all-cause-adjusted mortality rates after hip fracture repair. Observational study on virtually all potentially eligible hip fracture patients treated in 2240 hospitals from Ontario (Canada), Aragon (Spain), Finland, Sweden, and the USA (40 states). The primary endpoint was the risk-adjusted all-cause mortality after hip repair measured 30 days and 180 days after surgery. Following a federated approach, GAMM-logit models were run for each region. Median odds ratio (MOR) were estimated to elicit the variation at hospital level. The study included 535 519 hip repairs. The overall predicted 30-day adjusted mortality rate was 40.5 per 1000 hip repair episodes; 136.3 per 1000 hip repair episodes in the 180-day adjusted mortality rate. 30- and 180-day adjusted mortality rates were larger within the regions than across regions. Variance in patients’ mortality at the hospital provider accounted for MOR: 1.43 in 30-day mortality and MOR: 1.35 in 180-day mortality. Beyond differences in the individual risk of death, our study found wide systemic variations in mortality rates in older adult patients exposed to hip fracture repair attributable to the hospital of treatment. Our results call for a reorientation of care pathways after hip repair in frail patients, both in the short- and the long-term.

The English National Health Service (NHS) is a publicly funded system, however significant disparities in provision exist. Whereas the national picture of the distribution of Intensive Care Unit (ICU) beds has increased over time, less is understood about the regional variation in the rate of growth in ICU services and whether this is related to population growth. The aim of this study was to describe the national variation in the supply of ICU beds in England and evaluate whether there has been a narrowing of the regional disparities in providing ICU beds over time.

In the most recent National Health Expenditure (NHE) Projections, for 2024-33, Sean Keehan and colleagues at the Centers for Medicare and Medicaid Services (CMS) predict strong growth in health care expenditures in 2024, and average annual growth over the entire projection period that exceeds growth in GDP. According to their projections, health care is set to comprise 20.3 percent of GDP by 2033. This increase in health spending is expected despite declines in coverage, prompted by the continued unwinding of Medicaid pandemic policies and lower enrollment in private insurance stemming from the expiration of the IRA’s temporarily enhanced premium tax subsidies for Marketplace plans.

The Publication-of-the-Year Award recognizes the best and most relevant peer-reviewed, scientific work that the fields of health services research and health policy have produced and published in the prior calendar year.

Publication-of-the-Year Award
Differential Legal Protections for Biologics Vs Small-Molecule Drugs in the U.S.
Olivier J. Wouters, Ph.D.

The past two decades have seen a surge in available patient safety metrics. However, the variability in how healthcare organizations choose and monitor these metrics remains unknown. We cataloged the metrics organizations chose and how actively they monitored them. We investigated factors influencing the monitoring of patient safety metrics using surveys and in-depth interviews with patient safety experts from 11 Harvard-affiliated organizations.

In this piece we examine three forms of coercive or otherwise involuntary care that can occur with patient consent. To do so, we examine: (1) uninformed consent, (2) contingency-based consent and (3) constrained-market consent, amongst female sterilization patients. While there is broad recognition that “coercion” in sterilization care can manifest beyond instances of overt force and clarity on what constitutes coercion within clinical care, this has not translated to accountability. The current practice of identifying coercion through discrete civil cases may facilitate a narrow understanding of its contemporary prevalence; one that does not align with definitions of coercion supported by international human rights entities. We use three acute, and widely recognized, examples—hysterectomies in ICE detention facilities, India’s sterilization camp deaths and birth control quotas for Uyghur women—as an entry point to highlight less overt contemporary forms of coercive sterilization care, pairing each example with data that explores prevalence at a broader population level. These data suggest less visible forms of coercion may persist relatively unchallenged—raising the ethical case for a functional approach to the measurement of coercion. In turn, we argue the relevant question may not be “when is coercion ethically justified in public health,” but rather, why is coercion already the status quo?