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.