Health affairs scholar最新文献

{"title":"Marketplace coverage during pregnancy: what can we learn from state-level variation?","authors":"Julia C P Eddelbuettel, Alison A Galbraith, Sarah H Gordon, Anjali Kaimal, Laura F Garabedian","doi":"10.1093/haschl/qxag233","DOIUrl":"10.1093/haschl/qxag233","url":null,"abstract":"<p><strong>Introduction: </strong>Little is known about the role of the Affordable Care Act Marketplaces in providing health insurance coverage for pregnant women.</p><p><strong>Methods: </strong>Using PRAMS survey data from 2018-2019 from 36 states and Washington, DC, we estimated the percentage of women with a pregnancy resulting in live birth who had Marketplace coverage during pregnancy, overall, by state, by federal poverty level (FPL) categories, and by state-based vs federal Marketplace status. We also describe the preconception and postpartum insurance status and sociodemographic and health characteristics of pregnant Marketplace enrollees.</p><p><strong>Results: </strong>Overall, 4.9% of women who had a live birth had Marketplace coverage during pregnancy in 2018-2019. This percentage varied by state (1.6% in Iowa to 13.1% in Maryland) and was significantly higher in state-based Marketplaces vs federally-run/facilitated Marketplaces (8.0% vs 3.5%) and among premium subsidy-eligible women (ie, <400% FPL). Pregnant Marketplace enrollees were more similar to pregnant women with Medicaid than those with private insurance in terms of sociodemographic characteristics and clinical predictors of adverse pregnancy outcomes.</p><p><strong>Conclusion: </strong>Marketplace coverage is a small, but important coverage source for women who had a live birth, insuring 1 in 20 women in our sample. The extent to which pandemic-era and recent policies affected Marketplace coverage of this population merits further investigation.</p>","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag233"},"PeriodicalIF":4.1,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13596735/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149027200","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effects of the enhanced nurse licensure compact on interstate mobility and nursing employment.","authors":"Hong-Lun Tiunn, Qian Eric Luo, Jordan Herring, Patricia Pittman","doi":"10.1093/haschl/qxag221","DOIUrl":"https://doi.org/10.1093/haschl/qxag221","url":null,"abstract":"<p><strong>Introduction: </strong>The United States continues to face persistent nursing shortages, even as many licensed nurses are not employed in nursing roles. The enhanced Nurse Licensure Compact (NLC 2.0), a mutual licensure recognition agreement, is promoted as a strategy to increase workforce supply and flexibility, yet no prior research has assessed whether it helps licensed but nonpracticing nurses return to the profession.</p><p><strong>Methods: </strong>Using American Community Survey data (2010-2023) and state-level licensure and employment data (2015-2023), we evaluated whether NLC 2.0 adoption is associated with changes in interstate registered nurse (RN) inflows and in the license-employment mismatch-the share of active licenses not linked to payroll nursing employment-across 26 states.</p><p><strong>Results: </strong>We found no statistically significant effect on interstate migration (+0.27 percentage points; <i>P</i> = 0.67). However, adoption was associated with a 3.30-percentage-point reduction in the share of licensed nurses not employed in nursing (<i>P</i> = 0.054), with the effect strengthening over time. A staggered difference-in-differences robustness check confirmed this pattern.</p><p><strong>Conclusion: </strong>These findings suggest that while the compact does not draw nurses across state lines, it is associated with more licensed nurses working in nursing within adopting states. Licensure reform may therefore be one component of a broader strategy to support nurses' return to bedside roles.</p>","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag221"},"PeriodicalIF":4.1,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13655451/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149187095","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Financing and health system capacity for precision medicine in Asia: a six country landscape analysis.","authors":"Adena Li Tyin Peh, Yot Teerawattananon, Jeanette Xue Yan Yuen, Nordin Charafi, Dicky Levenus Tahapary, Jiahua Leng, Alec Morton, Sheyu Li, Woo Jin Kim, Bin Alwi Zilfalil, Hidayati Husainy Hasbullah, Nusara Satproedprai, Shao-Tzu Li, Joanne Yuen Yie Ngeow, Yah Ru Juang, Yue Zhang, Minji Hong, Wenjia Chen","doi":"10.1093/haschl/qxag238","DOIUrl":"10.1093/haschl/qxag238","url":null,"abstract":"<p><strong>Background: </strong>Precision medicine (PM) adoption is accelerating across Asia, but implementation remains uneven due to differences in financing, infrastructure, governance, and health-system readiness.</p><p><strong>Objectives: </strong>To examine how six Asian countries (Singapore, South Korea, China, Malaysia, Thailand, and Indonesia) adopt, finance, and integrate PM technologies, and identify common implementation patterns and challenges.</p><p><strong>Methods: </strong>A landscape review of peer-reviewed literature, government publications, and HTA reports (2010-2026) was conducted, supplemented by stakeholder consultations. PM applications were grouped into public health screening (hereditary breast and ovarian cancer [HBOC] and familial hypercholesterolemia [FH] cascade testing), next-generation sequencing (NGS) applications (rare diseases, oncology, pharmacogenomics), and AI-enabled PM. Evidence was synthesized across access, awareness, reimbursement, and implementation.</p><p><strong>Results: </strong>Public health genomic screening demonstrated the highest implementation readiness, followed by precision oncology, while rare disease diagnostics remained infrastructure-dependent and pharmacogenomics and AI-enabled PM platforms were at earlier stages. Four readiness profiles emerged: highly aligned systems; reimbursement-constrained systems with strong governance and infrastructure; systems strengthening governance, public financing and infrastructure; and strategy-led systems expanding implementation through pilot programs and referral centers.</p><p><strong>Conclusions: </strong>PM implementation across Asia remains heterogeneous. The identified readiness profiles highlight governance, financing, and infrastructure priorities for sustainable and equitable PM diffusion.</p>","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag238"},"PeriodicalIF":4.1,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13564229/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148957676","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"History of drug pricing reform in the United States: from policy foundations to latest reforms.","authors":"Sujith Ramachandran, Arman Arabshomali, John Coster","doi":"10.1093/haschl/qxag216","DOIUrl":"10.1093/haschl/qxag216","url":null,"abstract":"<p><p>This article examines the historical evolution of prescription drug pricing policy in the United States from the 1960s through 2025, highlighting how incremental reforms have produced a complex and fragmented system. It traces the foundations of drug pricing across Medicaid, Medicare, the Veterans Affairs (VA) system, and the 340B Drug Discount program, emphasizing the development of key pricing benchmarks such as Average Wholesale Price (AWP), Average Manufacturer Price (AMP), and Average Sales Price (ASP). The analysis details major legislative milestones affecting drug pricing, including the Omnibus Budget Reconciliation Act (OBRA) of 1990, the Medicare Modernization Act (MMA) of 2003, the Affordable Care Act (ACA) of 2010, and the Inflation Reduction Act (IRA) of 2022, and explains how these reforms reshaped reimbursement, rebates, cost of the prescription drugs, and access to medications. The article also identifies the various consequences of policy design, including the Medicaid \"best price\" provisions, growth in state Medicaid program supplemental rebates, and changes in prescription drug spending and reimbursement. Understanding the trajectory of policy reform is critical to identifying opportunities for improving affordability, access, and transparency in prescription drug markets.</p>","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag216"},"PeriodicalIF":4.1,"publicationDate":"2026-08-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13564212/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148957727","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Primary care physician characteristics and potentially inappropriate medications in older adults.","authors":"Yuki Tatsuno, Catherine A Sarkisian, John N Mafi, Kei Kitajima, Daichi Sato, Yusuke Tsugawa, Atsushi Miyawaki","doi":"10.1093/haschl/qxag227","DOIUrl":"10.1093/haschl/qxag227","url":null,"abstract":"<p><strong>Background: </strong>Potentially inappropriate medications (PIMs) are a growing public health concern. While research in North America suggests physician characteristics were associated with PIM prescription, their generalizability to other countries remains understudied.</p><p><strong>Methods: </strong>We conducted a cross-sectional study using a nationwide electronic health record database of primary care clinics in Japan. We analyzed patients aged ≥75 years who visited solo-practice physicians at least quarterly during October 2022 to September 2023. Multivariable logistic regression, adjusted for patient characteristics, was used to examine the association between physician characteristics and PIM prescriptions, defined as at least one medication listed in the Screening Tool for Older Person's Appropriate Prescriptions for Japanese for ≥28 days.</p><p><strong>Results: </strong>Among 184 097 patients treated by 1532 physicians, 70 319 (38.2%) received at least one PIM. Approximately two-thirds of PIM prescriptions were concentrated among 20% of the physicians. Younger physicians (adjusted odds ratio [aOR], 1.27; 95% CI, 1.05-1.55), physicians with lower volumes of older patients (aOR, 1.39; 95% CI, 1.19-1.61), and physicians in eastern or central Japan were more likely to prescribe PIMs.</p><p><strong>Conclusions: </strong>PIM prescriptions were common and concentrated among a subset of physicians, particularly younger and less experienced physicians. Targeted interventions among high prescribers may reduce PIM efficiently.</p>","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag227"},"PeriodicalIF":4.1,"publicationDate":"2026-08-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13564219/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148956774","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Primary care, weather, and the missed opportunity for savings.","authors":"Maranna Yoder, Nilesh Shinde, Guangqing Chi, Seth Freedman, Kosali Simon, Sonia Angell","doi":"10.1093/haschl/qxag225","DOIUrl":"10.1093/haschl/qxag225","url":null,"abstract":"<p><p>Extreme weather is a recurring source of stress on healthcare delivery, yet health systems remain largely reactive. Unlike an individual medical emergency, which the system absorbs one case at a time, a heat wave, wildfire smoke episode, or storm affects an entire population simultaneously. The resulting surge degrades care for every emergency patient, not only those the weather directly harmed. Primary care that anticipates weather-related risk and intervenes proactively can blunt that surge, but a central barrier to scaling such care is economic rather than clinical. Conventional prevention accounting counts only the benefit to the treated patient, and fee-for-service payment offers primary care practices only limited and poorly matched means to fund anticipatory care. Payment models that reward keeping patients healthy, such as global budgets, can address this, but only if risk adjustment accounts for environmental exposure so that providers serving vulnerable populations are not penalized. To address this, we outline 4 priorities: evaluations that capture system-wide costs; payment that rewards anticipatory care and adjusts for environmental risk; supply-side resilience in primary care, built jointly with public health agencies; and data infrastructure linking exposure to healthcare utilization.</p>","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag225"},"PeriodicalIF":4.1,"publicationDate":"2026-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13535243/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148883087","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"\"Am I a candidate for magic mushrooms?\" A mystery shopper study of Oregon psilocybin service centers.","authors":"Danielle R Adams, Morgan Hartman, Lisa Gong, Suraj Shankar, Ruth Ling, Jacob T Steinle, Joshua S Siegel, Ginger E Nicol, Richard A Grucza, Jacob T Borodovsky, Leopoldo J Cabassa, Kevin Y Xu","doi":"10.1093/haschl/qxag231","DOIUrl":"10.1093/haschl/qxag231","url":null,"abstract":"<p><strong>Introduction: </strong>Oregon is the first US state to permit supervised psilocybin services through a nonmedical, wellness-based model. We examined what prospective clients with psychiatric histories encounter when contacting service centers, including how staff communicate about safety, eligibility, and cost.</p><p><strong>Methods: </strong>We conducted a mystery shopper study of 26 licensed service centers in Oregon (7/2025-9/2025), 4 of which closed before calls began, leaving 22 in the sample. We reviewed websites and conducted 2 waves of scripted phone calls portraying adults with depression. Website and call data were combined at the center level, counting an item as disclosed if it appeared online or during a call. Themes from call field notes were contextualized through structured debriefing interviews with service center staff.</p><p><strong>Results: </strong>Callers reached 15/22 centers, none of which permitted unsupervised consumption or immediate dosing without psychiatric assessment. Staff asked detailed questions about psychiatric comorbidities, addressing information gaps from websites, and none recommended discontinuing antidepressants. The median cost was $1900. Debriefing interviews described financial strain for service centers, with viability constrained by licensing fees and potential misalignment with cannabis-derived business models.</p><p><strong>Conclusion: </strong>Oregon's regulated model appears clinically cautious, while facing high costs for clients, facilitators, and service centers that limit scalability.</p>","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 10","pages":"qxag231"},"PeriodicalIF":4.1,"publicationDate":"2026-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13659005/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149187081","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"FDA drug quality assurance inspections: frequency, outcomes, and time to reinspection, 2008-2025.","authors":"Yunxiang Sun, Jeromie Ballreich, Joy Acha, Riya Modi, Mohammad Ali Alamdar Yazdi, Maqbool Dada, Tinglong Dai, Gerard Anderson, Mariana P Socal","doi":"10.1093/haschl/qxag229","DOIUrl":"10.1093/haschl/qxag229","url":null,"abstract":"<p><strong>Background: </strong>The U.S. Food and Drug Administration (FDA) inspections are central to oversight of the pharmaceutical manufacturing base, but long-term inspection and reinspection patterns remain incompletely characterized.</p><p><strong>Methods: </strong>We analyzed 25 629 FDA Drug Quality Assurance inspections conducted from October 2008 through December 2025. We described annual, regional, and outcome patterns. Linking inspections to facilities, we examined time to reinspection according to the outcome of preceding inspections.</p><p><strong>Results: </strong>Annual Drug Quality Assurance inspections declined from 1594 in 2019 to 461 in 2020 and increased to 1218 in 2025. The United States remained the largest single region of inspection activity, but its contribution declined over time. The proportion of favorable inspection outcomes (no action indicated-NAI) decreased from 40.0% before the pandemic to 19.3% during and 23.7% after. Unfavorable outcomes (voluntary action indicated-VAI-and official action indicated-OAI) increased accordingly. The mean reinspection interval was 3.18 years after NAI, 2.96 after VAI, and 2.12 after OAI (<i>P</i> < .001). Median times were 4.08, 3.51, and 3.02 years, respectively.</p><p><strong>Conclusion: </strong>FDA inspection activity had not returned to prepandemic levels by 2025. Unfavorable inspection outcomes were associated with earlier reinspection, consistent with risk-responsive oversight. However, the available data cannot establish whether follow-up was timely or adequate.</p>","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag229"},"PeriodicalIF":4.1,"publicationDate":"2026-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13564223/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148957690","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cost and utilization outcomes of pharmacist-led medication therapy optimization in a Medicare ACO population.","authors":"Hazem F Elewa, Joseph F Levy, Chintan Pandya, Steven E Goldberg, Travis A Morgan","doi":"10.1093/haschl/qxag223","DOIUrl":"10.1093/haschl/qxag223","url":null,"abstract":"<p><strong>Introduction: </strong>Medication-related problems are a persistent source of avoidable spending among Medicare beneficiaries, presenting an important opportunity to improve the quality of care for seniors and reduce financial burden on the Medicare program.</p><p><strong>Methods: </strong>We evaluated a pharmacist-led medication therapy optimization (MTO) program implemented in a Medicare accountable care organization population using a regression-adjusted difference-in-differences design with propensity score matching. The analysis included 1003 treated members and 14 031 matched controls contributing 334 531 member-months of claims data (2022-2025). The MTO program combined pharmacogenomic testing, a nine-vector medication-risk algorithm, comprehensive pharmacist review, and structured recommendations to prescribers.</p><p><strong>Results: </strong>MTO participation was associated with a statistically significant reduction in total medical costs (pooled average treatment effect on the treated: -19.4%, -$246 per member per month [PMPM]; <i>P</i> < 0.001). The treatment effect was strongly duration-dependent, growing from -4.7% in the first three months to -31.9% (-$462 PMPM; <i>P</i> < 0.001) beyond nine months of program benefit. All care settings showed significant reductions: inpatient admissions -43.1% (<i>P</i> < 0.001), emergency department visits -41.3% (<i>P</i> < 0.001), and outpatient visits -28.3% (<i>P</i> < 0.001).</p><p><strong>Conclusion: </strong>Medication therapy optimization was associated with significant cost savings. Parallel trends validation and a pronounced dose-response relationship support a causal interpretation. Short-duration evaluations are likely to substantially underestimate the full economic value of an MTO program.</p>","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag223"},"PeriodicalIF":4.1,"publicationDate":"2026-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13602420/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149042874","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"When nurses are held accountable for AI-driven clinical decisions, they must be engaged early and meaningfully.","authors":"Meghan Reading Turchioe, Ann Wieben, Carolyn Sun, Christina Baker, Benjamin J Galatzan","doi":"10.1093/haschl/qxag218","DOIUrl":"10.1093/haschl/qxag218","url":null,"abstract":"<p><p>Health systems are adopting AI-powered tools faster than policy can address the implications for clinician liability. Nurses, as the largest healthcare profession and the most proximal clinicians to patients, must decide whether to accept, modify, or override AI-derived recommendations, often while managing competing cognitive demands. Yet the question of who bears responsibility when AI contributes to patient harm remains unresolved in policy and case law. At the 2025 American Medical Informatics Association Annual Symposium, a structured debate examined whether nurses should be held liable for AI-assisted clinical decisions. Proponents argued that professional ethics, existing tort precedent, and the nurse's role as human-in-the-loop require accountability. Opponents countered that AI opacity, unfair liability distribution, and limited nurse agency in AI procurement preclude fair responsibility assignment. Two reforms are essential: meaningful nurse engagement throughout the AI lifecycle and nursing-specific considerations in AI legislation and regulatory frameworks.</p>","PeriodicalId":94025,"journal":{"name":"Health affairs scholar","volume":"4 9","pages":"qxag218"},"PeriodicalIF":4.1,"publicationDate":"2026-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13591276/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149019277","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}