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.

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.