Question: Did homicide of females aged 15 to 44 years (hereinafter, women of reproductive age) recover uniformly after the COVID-19 surge, or did post-2022 trajectories diverge across state abortion policy environments?

Findings: In this study of US mortality data from 2016 through 2024, national homicide mortality decreased after the COVID-19 surge, but post-Dobbs trajectories diverged between states with and without sustained abortion bans. The fitted homicide rate of women of reproductive age in states with total or near-total abortion bans was 7% higher than the modeled counterfactual in 2023 and 15% higher in 2024, corresponding to an estimated 48 and 87 excess deaths, respectively.

Meaning: The findings suggest that national decreases in homicide mortality may mask widening differences in homicide mortality among women of reproductive age across state abortion policy environments.

In July 2026, the online prediction-market platform Kalshi announced that users would soon be able to bet on the results of in-progress clinical trials. One such “contract” available for wagers, for example, asks whether POLARIS-AD, a phase 3 trial of the experimental Alzheimer’s drug AR1001, will meet its primary end point. Although heavily focused on sports betting, commercial prediction markets have expanded into areas including interest rates, elections, weather, and the Academy Awards. Kalshi is entering the drug-development space with contracts on end points in large, late-stage trials but is considering broadening its scope to include earlier-phase trials and additional outcomes, such as the number of reported adverse events for a drug. Other major platforms, including Polymarket, are also introducing betting on drug development.

Individuals in the US make up less than 5% of the global population but account for half of global drug spending, frequently paying prices 3 to 4 times higher than in peer countries. These high prices strain public budgets and affect patients directly, with 1 in 4 adults reportedly not filling a prescription because of cost.

The Trump Administration has made narrowing the gap between US drug prices and those in other countries central to its health care agenda through what it calls most-favored-nation (MFN) drug pricing. According to the administration, the goal of MFN is not only to lower US drug prices, but also to encourage manufacturers to raise prices abroad so that other countries pay their fair share of the costs of pharmaceutical innovation.

MFN’s emphasis on fairness has powerful political appeal. The pharmaceutical industry has successfully opposed health technology assessment in Medicare by raising concerns about rationing care. It is harder to argue that a drug should cost far more at a pharmacy in Niagara Falls, New York, than at a pharmacy just across the border in Niagara Falls, Canada. The same intuition applies across greater distances: why should a roofer in Frankfort, Kentucky, pay more for cancer treatment than a banker in Frankfurt, Germany?

Importance: Patent protection allows pharmaceutical companies to charge high prices for prescription drugs during periods of market exclusivity, and their expiration usually defines when generic competitors can enter the US market. Patents on drug active ingredients are classified as primary patents, while patents on formulations, methods of use, and delivery devices are nonprimary.

Objective: To evaluate how pharmaceutical patent portfolios for US Food and Drug Administration (FDA)–approved drugs have evolved over time.

Evidence Review: Patents on small-molecule drugs approved by the FDA from 1990 to 2019 were examined and assessed for changes in the number and types of patents per product. The additional duration of total patent exclusivity associated with each patent type was quantified, and how often patents of each type were enforced against generic manufacturers in litigation was determined.

Findings: The FDA approved 1981 small-molecule drugs during the study period, and manufacturers listed 10 940 patents on these drugs. The mean number of patents per drug increased from 2.1 in 1990 to 6.9 in 2019, driven primarily by nonprimary patents. The mean number of nonprimary patents per drug rose from 1.2 in 1990 to 5.6 in 2019. Nonprimary patents represented majorities of FDA-listed patents (84% [9236/10 940]) and litigated patents (87% [4586/5253]). Nearly all patents listed after drug approval were nonprimary (96% [4874/5064]), and these patents extended market exclusivity by a mean of 6.1 years (SD, 5.8 years) and a median of 4.7 years (IQR, 0.2-10.1 years).

Conclusions and Relevance: Pharmaceutical patent portfolios have grown over the last 2 decades. These portfolios have largely been built on nonprimary patents, which are then enforced against generic firms at higher rates than primary patents. Large patent portfolios can complicate routine generic competition and prolong periods of high drug prices.

Most-favored-nation (MFN) pricing is central to the Trump administration's prescription drug agenda. It aims to prevent drug companies from charging higher prices in the United States than in other developed countries. In December 2025, the Centers for Medicare and Medicaid Services proposed 2 mandatory MFN demonstration models: GLOBE for Medicare Part B and GUARD for Medicare Part D. Both models would require manufacturers to pay Medicare rebates when US prices exceed international benchmarks.

The administration has separately announced voluntary MFN agreements with 26 drug manufacturers under which participating companies provide MFN pricing in Medicaid, offer direct-to-consumer discounts, make launch-price commitments, and invest domestically.3 The agreements also appear to exempt participating manufacturers from other federal pricing initiatives, including GLOBE and GUARD. At least 10 manufacturers have publicly disclosed or confirmed exemptions from Medicare pricing demonstration models in securities filings, investor disclosures, earnings calls, and comments to the Centers for Medicare and Medicaid Services. Some explicitly identify GLOBE and GUARD as covered exemptions. The administration has neither confirmed nor denied these exemptions but has explicitly reserved discretion to exempt manufacturers participating in other drug pricing initiatives.

Despite concerns raised by commentators and legislators, the administration has released no estimate of the impact on the model-eligible spending base if the 26 manufacturers with voluntary agreements are exempted from GLOBE and GUARD.

In this study, we estimated the 2024 Medicare spending base on drugs meeting the proposed criteria for GLOBE and GUARD and quantified the share from products marketed by manufacturers with voluntary MFN agreements.

Health care accounts for nearly one-fifth of the US economy, and national health expenditures are projected to exceed 20% of gross domestic product by 2033.1 After decades of concern about rising expenditures, growing evidence suggests that the US has experienced a sustained slowdown in health spending growth relative to historical trends and earlier projections.2 Whether the US has successfully “bent the cost curve” has become a prominent focus of health policy debate.

Yet spending growth is only one dimension of sustainability and should be considered alongside spending levels and the distribution of financial burden. During the period in which the US bent the cost curve, the disconnect between health care spending, affordability, and population health outcomes has become increasingly pronounced.3,4 For a country that already devotes far more resources to health care than any other,5 even modest growth may have important implications for affordability and access while raising persistent questions about whether spending levels generate sufficient value.

Given the already high level of US health care spending and growing concerns about affordability, policymakers face a fundamental challenge: improving affordability often requires investment, yet additional spending is increasingly difficult to accommodate. Recent increases in health care spending also suggest that the slowdown observed over the past decade may not persist.1 In this context, the critical question for policymakers is not whether but how spending growth over the next decade can be constrained. We argue that 5 interconnected forces will shape not only how much the US spends on health care, but also who bears those costs and whether health gains are achieved in return.

The United States spends more on health care than any other country, yet its fragmented financing structure masks the full financial burden that individuals bear through taxes, premiums, and out-of-pocket payments. A sizeable number of people contribute to the health care financing of others while they themselves remain uninsured. This cross-sectional study used 2023 Current Population Survey Annual Social and Economic Supplement data to quantify health care contributions among US tax filers, by income quintile, payment type, and sociodemographic characteristics. Although total contributions were higher at each successive income quintile, out-of-pocket spending fell disproportionately on lower-income and sicker people. Uninsured tax filers younger than age sixty-five contributed approximately 64 percent of what their insured counterparts paid, despite lacking coverage. Virtually all tax filers contributed to US health care financing through its public financing streams, yet many remained exposed to significant financial risk or lacked coverage altogether. This reflects the fragmented structure of US health care financing, where financial contributions are not aligned with coverage or protection from medical costs.

Health systems face financial pressures as populations age and economic growth slows, with implications for who pays for health care and for what drives expenditure growth.

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.

Background: Kidney transplantation (KTx) practices vary across healthcare systems, yet the operational components of best practice (BP) along the clinical pathway remain incompletely defined. This study aimed to identify key best practice elements across the kidney transplantation journey in four European countries.Methods: A mixed-methods study was conducted across France, Germany, Italy, and Spain. A structured survey (n = 253 respondents, including patients, living donors, nephrologists, transplant surgeons, transplant coordinators, and hospital administrators) assessed clinical practice and patient experience across four domains: CKD management, kidney donation and transplantation, transplant recipient care, and service governance. Semi-structured focus group interviews were performed in each country to contextualise survey findings. Ethics approval was obtained in accordance with national requirements.Results: Key elements for best practices along the KTx clinical journey were identified: (1) development of protocols to standardise the variable monitoring of CKD, to minimize urban-rural differences in clinical practice due to limited resources and follow-up care; (2) enhanced primary care training and targeted resource allocation to diagnose and monitor early-stage CKD; (3) donor coordination and promotion of living donation, addressing gaps in patient awareness and access to care; (4) development of communication protocols on living donation; (5) implementation of targeted patient and donor educational campaigns on living donation; (6) enhanced post-transplant follow-up care by nephrologists; (7) integration of quality-of-life assessments and psychological donor support post-transplantation; (8) increased availability of transplant coordinators to promote equitable resource allocation and the adoption of innovative practices; (9) streamlined governance structures along clinical journey; and (10) equitable funding models with consistent reimbursement policies across patient groups.Conclusions: This study provides a cross-national, mixed-methods framework for strengthening equity, coordination, and quality in kidney transplantation. Addressing variability in monitoring pathways, referral structures, patient-centred outcomes, and workforce capacity may enhance implementation of international transplantation guidelines and improve patient and donor outcomes.

The general prevalence of chronic non-communicable diseases, such as diabetes mellitus is rapidly increasing while exacerbating the burden of disease on healthcare systems. Its management, as opposed to communicable diseases, is typically long term and requires ongoing healthcare interventions, such as dietary control and medication prescription, with associated costs. The prescription requires an interaction between patients and physicians, which may be sporadic or continuous, and can be used as a proxy measure for the strength of patient–doctor relationship. We hypothesize that fragmentation of care, across physician specialties and payers, plays a role on prescription behaviour, above and beyond for patient and prescription characteristics. A panel of patients’ prescriptions events with the universe of all prescriptions and dispensing in Portugal from January 2015 to October 2019 (N = 791.467) provided by Serviços Partilhados do Ministério da Saúde, EPE was considered. We measured the association between care fragmentation of care and prescription behavior of antihyperglycaemic medication using negative binomial regression models. Results suggest that Specialists play a secondary role on the prescription of DPP-4i and SGLT2i, prescribing 12.3 and 4.3% less respectively, while playing a central role on the prescription of GLP-1, in comparison with GPs. Fragmentation of care also plays a part on prescription trends, i.e., physicians with higher of continuity of care present higher rates of prescription of approximately 5.9% for DPP-4i, 6.5% for SGLT2i and 39.6% for GLP-1. The comparison of prescription trends amongst public and private payers suggests that public payers have lower rates of prescriptions (DPP-4i: 9.6%; SGLT2i: 7.2%; GLP-1: 85.6%). We find important differences in prescription patterns between specialists and primary care physicians. Higher continuity of care is associated with increased prescription frequency. Finally, public payers are associated with lower prescription rates. Physician specialty, payer, and care fragmentation all interact in the prescription patterns of antihyperglycaemic medication.

Hospitalizations for Ambulatory Care Sensitive Conditions (ACSCs) are thought to be avoidable with effective preventive care and early disease management, usually delivered in community-based ambulatory care settings. These hospitalizations are both costly and sensitive to the socioeconomic situation of patients. Understanding whether different health systems mitigate the sensitivity of ACSCs to socioeconomic gradients may direct attention to equity-improving approaches to ambulatory health care. This study sought to identify differences in the gradient of Ambulatory Care Sensitive Conditions (ACSC) relative to socioeconomic status across nine countries, namely Australia, Canada, England, Finland, France, New Zealand, Spain, Switzerland, and the United States (US).

For decades, policy makers have struggled to improve care and control costs for medically complex and socially vulnerable populations, particularly individuals dually eligible for Medicare and Medicaid. Dual-eligible beneficiaries experience high rates of chronic illness, disability, and unmet social needs, and they account for a disproportionate share of Medicare and Medicaid spending. Despite sustained efforts to shift payment from volume to value, performance-based models have often yielded uneven results among providers serving these populations. In Medicare’s Accountable Care Organization (ACO) programs, organizations caring for higher proportions of racial and ethnic minority beneficiaries and socially vulnerable patients have faced greater challenges achieving savings and sustaining participation. These patterns highlight a central dilemma in value-based payment: without careful risk adjustment and benchmarking, models designed to reward quality of care and efficiency may disadvantage providers serving communities with concentrated social risk.

Burnout and decreased well-being among primary care physicians threaten workforce sustainability and health outcomes. Understanding how primary care physician burnout and its mitigators differ across countries could inform policy changes, but evidence is limited. Using 2012–22 survey data from primary care physicians in the United States and nine other high-income countries, we found that shares reporting stress rose across countries. By 2022, the US had one of the highest shares of primary care physicians reporting burnout (44 percent). Switzerland (18 percent) and the Netherlands (12 percent) had the lowest shares reporting burnout, alongside higher shares with satisfaction and lower shares with stress. Across countries, female physicians had higher odds of burnout, whereas workplace factors—including satisfaction with income and administrative workload—and better care quality were associated with reduced odds of burnout. Efforts to reduce burnout should address disparities by sex and should include systemic supports including quality initiatives, flexible work, and arrangements for patient cross-coverage; in-depth cross-national learning could reveal additional strategies.

For more than two decades, debates about why US health care spending is so high have been shaped by the insight articulated by Gerard Anderson, Uwe Reinhardt, and Peter Hussey: that the United States does not use more health care than other high-income countries but pays much higher prices for it. The original “It’s the Prices, Stupid” argument was fundamentally about price levels, not price growth. That central insight remains as true today as when it was first articulated: across services, drugs, and inputs, the United States consistently pays substantially higher prices than its peers for comparable services, drugs, and inputs.

Female sterilization occupies a paradoxical place in reproductive policy. When chosen freely, it is a safe and effective contraceptive method, yet has also been deployed as a tool of coercion and state control. This dual legacy makes the United States, where sterilization remains more common than other high-income democracies, an important case for examining how public accountability and policy design shape permanent contraceptive use. From a theoretical perspective, highly visible, accountability-driven interventions such as the 1974 Relf v. Weinberger case might be expected to generate larger behavioral changes than less visible administrative reforms, though prior scholarship offers mixed expectations about the relative influence of legal visibility versus economic incentives. To test these competing expectations, we analyze a harmonized panel of contraceptive surveys from 190 nations (1965-2010) and apply the synthetic-control method. We examine the behavioral impact of Relf as a democratic accountability event and contrast it with a later unrelated administrative change in U.S. hospital reimbursement policy in the 1990s. We find that the public outrage and litigation following Relf produced formal consent safeguards but were associated with limited changes in the national sterilization rates. In contrast, the 1990s payment reforms, aimed at cost containment, were associated with a sustained national decline. Together, these contrasting impacts suggest that reforms driven by court decisions and financial architecture may influence entrenched policies through different, potentially complementary, channels. Taken together, the findings affirm the important role of administrative levers alongside legislative activism, levers often overlooked in reproductive rights debates despite their capacity to reshape clinical practice.

Factors influencing the timing of regulatory submission for new drugs across countries are poorly understood. We identified all new drugs approved by the Food and Drug Administration (FDA) or European Medicines Agency (EMA) during the period 2014–18 and tracked their regulatory submissions to the US, the European Union, Canada, Japan, and Australia through 2022. We assessed whether disease area, orphan status, therapeutic value, market size, and launch price were associated with submission delays. The FDA received the highest proportion of first submissions (70 percent). Median submission delays ranged from zero months (FDA) to 18.5 months (Australia). The range of median regulatory review times was small (9.2–14.1 months) compared with the range of median submission delays. Drugs with moderate-to-high therapeutic value were associated with a six-month earlier submission time compared to drugs with low therapeutic value, on average. Higher-price drugs were associated with earlier submission, on average. Overall, cross-national differences in drug availability largely reflected differences in submission, not regulatory review, times. Although the US had greater and faster availability of novel therapeutics, the difference was smaller for drugs that offered moderate-to-high therapeutic value.

Private equity (PE) firms are increasingly investing in healthcare, seeking short-term returns through market consolidation, price increases, asset sales, and financial engineering. Although PE is transforming the healthcare sector, many countries lack systematic data to determine whether a regulatory response is warranted. Using data from PitchBook, we document substantial and growing PE investment in health care across 25 of 38 Organization of Economic Cooperation and Development (OECD) countries, totalling over 8,400 reported deals and $1.4 trillion in capital between 2013 and 2023. Outpatient clinics represent the dominant target of investment, while hospital and elder care sectors have attracted investments in select countries. Exploratory regression analyses suggest that PE firms are less likely to invest in countries with a social health insurance system and that PE deal volume is positively associated with health expenditures. Country-specific deviations from model predictions underscore the importance of unmeasured country-specific factors such as regulation, payment policy, and market competition. Eight case studies illustrate the operational, financial, and social implications of PE investments, as well as diverse regulatory contexts. Given the lack of disclosure requirements, a key policy priority for governments is to enhance transparency to enable effective monitoring of the financialisation of health care delivery.

Question: How have medical device patents contributed to periods of market exclusivity on drug-device combinations?

Findings: In this cohort study of 331 drug-device combinations approved by the Food and Drug Administration (FDA) from 1986 to 2023, 1751 of 3241 individual patent listings were on the delivery devices of these products. Medical device patents extended periods of protection for 180 products (54.4%) by a median (IQR) of 7.5 (2.8-13.9) years, with most device patents failing to mention the active pharmaceutical ingredients in their claims.

Meaning: Patenting strategies on drug-device combinations may impede generic entry and keep prices high for patients and payers.

Background: The Global Fund to Fight AIDS, Tuberculosis, and Malaria is one of the world’s largest global health donor agencies, playing a key role by filling recipient countries’ domestic health financing gaps; however, little is known about how well it achieves value for money. Given the current uncertainty regarding global health development assistance, it is critical to understand how to prioritize external donor funding allocations in an effort to maximize health impact.

Methods: In this study, we evaluated 66 recipient countries’ efficiency relative to peers in achieving improvement in health outcomes for TB, malaria, and HIV given their 2017–2019 Global Fund expenditures for (1) health products, (2) program activities, and (3) program management. Using a combination of frontier analysis, linear regression, and cluster analysis, we examined how macroeconomic conditions, epidemiological context, health system factors, and Global Fund spending decisions explain variation in country program performance.

Results: For malaria and HIV, we found a negative relationship between Global Fund spending on program activity and health product costs respectively and countries’ efficiency at translating funds to health impact. For malaria and HIV, there was also significant variation in efficiency across countries according to their economic capacity, disease burden, and most prominent spending area.

Conclusions: Our results suggest possible structural inefficiencies in country program management, dampening the health impact of frontline programs. The lack of broad patterns to predict performance signals the importance of tailoring spending strategies to country-specific contexts.

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.