Importance:Social media use is nearly ubiquitous among US teenagers and young adults and has been associated with increased risk for negative health outcomes such as depression and anxiety. Policymakers in several states have proposed or adopted policies requiring warnings on social media platforms. Objective:To test whether teenagers and young adults perceive that social media warnings discourage them from wanting to use social media and increase their awareness of the harms of social media. Design, Setting, and Participants:This within-participants randomized clinical trial was conducted online in December 2025 among US teenagers and young adults aged 13 to 29 years. Interventions:Participants viewed 15 messages shown in random order: 13 health warnings about different harms (eg, negative body image, and depression and anxiety), a screen time break warning similar to messages voluntarily displayed on some social media platforms, and a neutral control message. Messages were displayed on a mock social media page. Main Outcomes and Measures:Participants rated each message on a 1 to 5 scale for perceived message effectiveness for discouraging social media use (primary outcome) and awareness of the harms of social media (secondary outcome). Linear mixed models were used to estimate differences in outcomes between message topics, expressed as average differential effects (ADEs). Results:A total of 1012 participants (mean [SD] age, 19.3 [4.5] years; 509 women and girls [50%], 491 men and boys [49%], and 12 individuals who identified as nonbinary or another gender [1%]) completed the study. Participants perceived all health warnings as well as the screen time break warning as more effective than the control message (range of ADEs, 0.32 [95% CI, 0.24 to 0.41] to 0.62 [95% CI, 0.53 to 0.71]). Participants perceived all health warnings as more effective than the screen time break warning (range of ADEs, 0.16 [95% CI, 0.08 to 0.24] to 0.30 [95% CI, 0.22 to 0.37]), except for the health warning about addiction (ADE, 0.07 [95% CI, -0.004 to 0.14]). Similarly, participants perceived all warnings as increasing their awareness of the harms of social media more than the control message (range of ADEs, 0.19 [95% CI, 0.10 to 0.28] to 0.63 [95% CI, 0.54 to 0.72]) and all health warnings as increasing their awareness more than the screen time break warning (range of ADEs, 0.21 [95% CI, 0.13 to 0.28] to 0.44 [95% CI, 0.36 to 0.52]). Conclusions and Relevance:These findings of this randomized clinical trial suggest that requiring warnings on social media platforms could increase awareness of the harms of social media and discourage teenagers and young adults from wanting to use social media. Trial Registration:ClinicalTrials.gov Identifier: NCT07199660.
This Viewpoint describes potential concerns and opportunities with a single-trial default for US Food and Drug Administration (FDA) drug approval.
Importance:Chronic pain affects roughly 50 million US adults and often co-occurs with mental health conditions. Although mental health treatment can improve outcomes, little is known about how insurance type relates to utilization among adults with chronic pain. Objective:To examine how insurance type relates to mental health service utilization among adults with chronic pain, whether this association varies by mental health need, and cost-related barriers to care. Design, Setting, and Participants:This cross-sectional study analyzed data from the National Institutes of Health's All of Us Research Program Mental Health and Well-Being off-cycle survey. Survey responses spanned June 2018 through September 2023. Participants were adults aged 18 years or older at survey completion with a chronic pain diagnosis documented before survey completion. Data were analyzed in January 2026. Exposures:Insurance type: private only (reference), Medicare only, Medicare plus supplement, Medicaid only, dual eligible, military or Veterans Affairs (VA), and other. Main Outcomes and Measures:Self-reported mental health professional visit in the past 12 months (primary) and cost-related barrier to needed mental health care (secondary). The utilization gap was defined as the percentage of participants with mental health need who reported no utilization. Results:Among 36 275 adults with chronic pain (mean [SD] age, 57.2 [15.0] years; 68.0% female), 34.0% reported seeing a mental health professional in the past 12 months. Among 7305 with mental health need, the utilization gap was 34.2% (n = 2497). Gaps varied by insurance: military or VA, 18.7% (95% CI, 15.8%-21.7%); dual eligible, 25.9% (95% CI, 22.8%-29.0%); Medicaid, 34.8% (95% CI, 32.8%-36.7%); Medicare, 36.6% (95% CI, 33.7%-39.7%); private, 40.9% (95% CI, 38.8%-43.0%), a private vs military or VA difference of 22.2 (95% CI, 18.6-25.6) percentage points. Cost-related barriers were highest among the privately insured (532 of 2070 [25.7%]) and lowest among military or VA enrollees (50 of 626 [8.0%]; adjusted prevalence ratio, 0.42; 95% CI, 0.32-0.55). Conclusions and Relevance:In this cross-sectional study, among adults with chronic pain and mental health need, utilization gaps were more than double under private insurance vs military or VA coverage, and cost barriers were substantially more common among the privately insured. These patterns are consistent with a role for affordability and integrated care delivery, though cross-sectional data cannot distinguish insurance design from selection into coverage types.
Importance Social media use is nearly ubiquitous among US teenagers and young adults and has been associated with increased risk for negative health outcomes such as depression and anxiety. Policymakers in several states have proposed or adopted policies requiring warnings on social media platforms. Objective To test whether teenagers and young adults perceive that social media warnings discourage them from wanting to use social media and increase their awareness of the harms of social media. Design, Setting, and Participants This within-participants randomized clinical trial was conducted online in December 2025 among US teenagers and young adults aged 13 to 29 years. Interventions Participants viewed 15 messages shown in random order: 13 health warnings about different harms (eg, negative body image, and depression and anxiety), a screen time break warning similar to messages voluntarily displayed on some social media platforms, and a neutral control message. Messages were displayed on a mock social media page. Main Outcomes and Measures Participants rated each message on a 1 to 5 scale for perceived message effectiveness for discouraging social media use (primary outcome) and awareness of the harms of social media (secondary outcome). Linear mixed models were used to estimate differences in outcomes between message topics, expressed as average differential effects (ADEs). Results A total of 1012 participants (mean [SD] age, 19.3 [4.5] years; 509 women and girls [50%], 491 men and boys [49%], and 12 individuals who identified as nonbinary or another gender [1%]) completed the study. Participants perceived all health warnings as well as the screen time break warning as more effective than the control message (range of ADEs, 0.32 [95% CI, 0.24 to 0.41] to 0.62 [95% CI, 0.53 to 0.71]). Participants perceived all health warnings as more effective than the screen time break warning (range of ADEs, 0.16 [95% CI, 0.08 to 0.24] to 0.30 [95% CI, 0.22 to 0.37]), except for the health warning about addiction (ADE, 0.07 [95% CI, −0.004 to 0.14]). Similarly, participants perceived all warnings as increasing their awareness of the harms of social media more than the control message (range of ADEs, 0.19 [95% CI, 0.10 to 0.28] to 0.63 [95% CI, 0.54 to 0.72]) and all health warnings as increasing their awareness more than the screen time break warning (range of ADEs, 0.21 [95% CI, 0.13 to 0.28] to 0.44 [95% CI, 0.36 to 0.52]). Conclusions and Relevance These findings of this randomized clinical trial suggest that requiring warnings on social media platforms could increase awareness of the harms of social media and discourage teenagers and young adults from wanting to use social media. Trial Registration ClinicalTrials.gov Identifier: NCT07199660
This cross-sectional study used Current Procedural Terminology codes and 2023 claims data to compare preventive care rates across Medicaid managed care organizations and employer-sponsored, Marketplace, and Medicare Advantage plans in Virginia.
Importance:Large shares of the US public are struggling to afford their health insurance. High premiums limit access to coverage. Rising premiums in the market for employer-sponsored health insurance, where the plurality of the privately insured get their coverage, are also causing reductions in wage growth, lowering employment, and fueling income inequality. Objective:To analyze the extent to which rising health insurance premiums reflect growth in health spending vs growth in markups in the large-group market, small-group market, and in the health insurance exchanges. Design, Setting, and Participants:This cohort study analyzed the 2011 to 2024 Public Use Files from the Medical Loss Ratio Data provided by the Center for Consumer Information and Insurance Oversight at the Centers for Medicare & Medicaid Services. The data include information on insurance premiums, health spending, and insurer markups and are published annually. These data include information on the large-group market, small-group market, and health insurance exchanges. Main Outcomes and Measures:Insurance premiums, health spending, and insurer markups (profits combined with administrative costs). Results:From 2011 to 2024, across the large-group market, small-group market, and health insurance exchanges, the enrollee-weighted mean of insurance premiums grew by 78.4% ($3143). In percentage terms, insurer markups decreased from 18.6% in 2011 to 14.9% in 2024. Ultimately, 91% of the growth in health insurance premiums was explained by growth in health spending (R2 = 0.91). Conclusions and Relevance:This cohort study found that rising health spending explained 91% of the growth in insurance premiums from 2011 to 2024. This finding suggests that efforts to slow the growth in health insurance premiums should focus on slowing growth in health care spending.
Importance:Administrative burdens, the time, effort, and stress of navigating bureaucratic requirements, impede Medicaid beneficiaries and persist even when care is obtained, yet their frequency and patient time costs are largely invisible in claims data. Objective:To measure administrative burdens documented in Medicaid care coordination notes by type, quantify the patient time costs they entail at multiple wage valuations, and characterize differences by race and ethnicity. Design, Setting, and Participants:Retrospective cohort study of Medicaid managed care beneficiaries in a single community-based care coordination program across Washington, Virginia, and Ohio from January 2023 through November 2025. Natural language processing classifiers identified administrative burdens in encounter notes. Exposures:Four documented administrative burden types: scheduling difficulties, transportation problems, paperwork and documentation requirements, and prior authorization delays. Main Outcomes and Measures:Patient-level prevalence and incidence by burden type; encounter-normalized rates; patient time costs at the federal minimum wage ($7.25/h), a state-weighted living wage ($22.00/h), and the Resource-Based Relative Value Scale conversion factor ($33.40/h); and differences by race and ethnicity. Results:Of 142 473 Medicaid beneficiaries (mean [SD] age, 31.6 [18.5] years; 55.3% female; 44.7% male) enrolled in the 4 participating managed care plans during the study period, 49 282 beneficiaries (34.6%; mean [SD] age, 33.7 [18.8] years; 60.5% female; 26.2% African American; 1.1% American Indian or Alaska Native; 3.8% Asian; 7.6% Hispanic; 0.9% Native Hawaiian or Other Pacific Islander; 35.0% White; 2.2% other race and ethnicity; 23.2% unknown ethnicity), completed at least 1 care coordination encounter. Patient-level prevalences were 6.1% (95% CI, 5.9%-6.3%) (transportation), 25.3% (95% CI, 24.9%-25.7%) (paperwork), 16.2% (95% CI, 15.8%-16.5%) (scheduling), and 9.8% (95% CI, 9.6%-10.1%) (prior authorization). Per affected patient, the mean time cost at the clinician-equivalent valuation was highest for transportation ($47.58; 95% CI, $45.75-$49.52) and lowest for scheduling ($12.35; 95% CI, $11.99-$12.73); documented burdens corresponded to 18 822 patient-hours cohortwide ($628 665). Encounter-normalized rates preserved this ordering, which was also robust to classifier misclassification. After excluding the 23.2% of beneficiaries with unknown ethnicity, a higher unadjusted burden prevalence was found in African American beneficiaries than White beneficiaries (rate ratio, 1.22; 95% CI, 1.18-1.25); payer-stratified analysis indicated this aggregate difference reflected enrollment in higher-burden plans rather than within-plan differences (<2 percentage points). Beneficiaries who engaged with care coordinators were older, more often female, and higher acuity than eligible beneficiaries who did not engage. Conclusions and Relevance:In this cohort study, administrative burdens in Medicaid varied markedly by type in both prevalence and patient time cost. Natural language processing of existing care coordination notes offers a scalable way for managed care plans and state Medicaid agencies to monitor which burdens are most common and most time-consuming.
Importance:House Resolution 1 (HR 1) of the 119th US Congress (2025-2026), known as the One Big Beautiful Bill Act, created national work-reporting requirements for adult Medicaid expansion enrollees starting by January 1, 2027. Although many expect the administrative burdens associated with work-reporting requirements to be the primary source of disenrollment, the impact of variable work hours and/or part-time work on potential disenrollment from Medicaid among low-income working adults is unknown. Objective:To assess the risk of noncompliance with national Medicaid work-reporting requirements due to insufficient and/or variable work hours after enactment of HR 1. Design, Setting, and Participants:This cross-sectional study used data from the 2023 to 2025 Current Population Survey (US) to describe employment of adults between 18 and 64 years of age who were plausible Medicaid-expansion enrollees. The prevalence of being at risk of noncompliance was estimated, and modified Poisson regression models were used to assess differential risk based on demographic characteristics. Data were analyzed from February through June 2026. Exposure:Work-reporting requirements under HR 1. Main Outcomes and Measures:Risk of noncompliance due to usually being near the 20-hours-per-week threshold and/or for reporting variable hours. Results:The analytic sample comprised 19 476 observations, representing a mean annual weighted population of more than 16 million individuals (mean age, 41.1 [95% CI, 40.8-41.3] years; 49.8% female and 50.2% male individuals), most of whom were unmarried (71.8%) and non-Hispanic White (47.9%) with a high school level or equivalent education (41.0%). Among them, we estimated that 19.8% of those potentially subject to work reporting requirements and working are at risk of noncompliance, by usually being near the hours threshold (13.6%) and/or reporting variable hours (7.6%). Female individuals had a 22% higher probability (adjusted risk ratio [aRR], 1.22; 95% CI, 1.11-1.35) of being at risk of noncompliance, whereas married respondents had an 18% lower probability (aRR, 0.82; 95% CI, 0.74-0.92). Significant variation was also observed by race and ethnicity and by education level. Conclusions and Relevance:This cross-sectional study found near full-time mean hours per week among working adults age 18 to 64 years enrolled in or likely eligible for Medicaid expansion. However, nearly one-fifth were at risk of noncompliance due to insufficient or variable hours.
This JAMA Forum discusses excess general fund revenue financing and the reasons why new reform priorities are needed for Medicare.
Importance:Patients frequently forgo filling prescriptions due to high out-of-pocket costs. Real-time prescription benefit (RTPB) tools that recommend available lower-cost, clinically equivalent medications to prescribing clinicians may increase the likelihood that patients fill their prescriptions. Objective:To determine whether availability of an RTPB tool increases prescription fill rates. Design and Setting:This post hoc analysis of a cluster randomized clinical trial included medical practices within an urban ambulatory clinical network randomized to the RTPB tool between January and December 2021. Outpatient prescriptions that were eligible for an RTPB recommendation during the study period were analyzed. Data analyses were performed from October 18, 2022, to August 9, 2024. Intervention:An electronic health record-integrated RTPB tool that displays available lower-cost and clinically equivalent alternatives to the initiated prescription at the point of prescribing. Main Outcome and Measure:The primary outcome measured whether a prescription was filled. Results:Of 1 386 577 outpatient prescriptions at randomized practices during the trial period, 38 289 (2.8%) were included in the analytic sample. Across all orders, the availability of the RTPB tool did not impact the proportion of orders filled (54% and 55% in the control and RTPB groups, respectively; adjusted difference: 1.2 percentage points [pp]; 95% CI, -1.3 to 3.7 pp). However, in the quartile of drug classes with the highest out-of-pocket costs (average out-of-pocket cost for a 30-day fill of >$120.83), fill rates increased from 33% in the control group to 49% in the RTPB group (adjusted difference: 14.5 pp; 95% CI, 8.4-20.6 pp). Similar increases were not detected in lower-cost drug classes. Increases in fill rates within the highest out-of-pocket cost drug classes were largest for patients in the lowest-income communities served by the health system (30.3 pp; 95% CI, 19.5-41.1 pp) but not substantial in the highest-income communities (1.0 pp; 95% CI, -10.2 to 12.2 pp). Conclusions and Relevance:In this post hoc analysis of a cluster randomized clinical trial, there was no change in overall prescription fill rates, but among high-cost drugs, the RTPB tool increased fill rates, particularly among patients from low-income communities. However, RTPB recommendations were made for a small proportion of orders, limiting the applicability of the findings to a narrow segment of the randomized population. Trial Registration:ClinicalTrials.gov Identifier: NCT04940988.
IMPORTANCE:Foster care entry is associated with long-term adverse outcomes for children and substantial public costs. Housing hardship is common among child welfare-involved families, and eviction moratoria implemented during the COVID-19 pandemic may have stabilized housing for at-risk families. Little is known about whether population-level housing policies, which are generalizable to the broader population, are associated with foster care entries. OBJECTIVE:To assess whether state eviction moratoria are associated with foster care entries. DESIGN, SETTING, AND PARTICIPANTS:This cohort study used a biweekly county panel spanning January 1, 2019, through mid-August 2021, comprising 59 counties across 16 states and Washington, DC (60 jurisdictions total). Counties were categorized as always-treated (states with eviction moratoria continuously in effect from mid-March 2020 through mid-August 2021) or never-treated (states with no statewide moratorium during the study window). A sensitivity analysis expanded the sample to include all-treated vs never-treated counties. Data were analyzed from January 1 to May 29, 2026. EXPOSURES:State eviction moratorium status in each county-biweekly period. MAIN OUTCOMES AND MEASURES:Biweekly counts of foster care entries overall and by recorded reasons. Adjusted negative binomial difference-in-differences models compared changes in entries in always-treated vs never-treated counties before vs after mid-March 2020, when moratoria were initiated. RESULTS:The analytic sample comprised 42 always-treated and 18 never-treated jurisdictions. In the primary analysis (always-treated vs never-treated counties), eviction moratoria were associated with a 31% reduction in foster care entries attributed to inadequate housing (incidence rate ratio [IRR], 0.69; 95% CI, 0.48-0.99), a 23% reduction in caregiver inability to cope (IRR, 0.77; 95% CI, 0.64-0.93), and a 20% reduction in physical abuse (IRR, 0.80; 95% CI, 0.64-0.99). The findings for total entries were directionally consistent (IRR, 0.88; 95% CI, 0.70-1.12) but were not statistically significant. In the expanded analysis (all-treated vs never-treated), caregiver inability to cope (17%; IRR, 0.83; 95% CI, 0.72-0.96) and inadequate housing (16%; IRR, 0.84; 95% CI, 0.74-0.95) were associated with reductions in foster care entries. CONCLUSION AND RELEVANCE:In this study, state eviction moratoria were associated with fewer foster care entries attributed to inadequate housing, caregiver inability to cope, and physical abuse. These findings suggest that housing stabilization policies may reduce foster care entries through direct housing-related and indirect stress-related pathways.
Importance:Anti-immigration policies in 2025 may influence outpatient care and telehealth among immigrant communities. Understanding visit patterns is essential for health systems leaders to prepare for shifts in health care use and ensure preventive care. Objective:To compare outpatient in-person and telehealth visit completion rates among patients classified as likely undocumented and those likely with legal status, before and after 2025 federal immigration policy changes. Design, Setting, and Participants:This cross-sectional study analyzed electronic health record data from outpatient encounters in a public safety-net system. Documentation status was approximated using non-English primary language without a Social Security number (SSN) to classify patients with likely undocumented status and using English primary language with SSN for patients likely with legal status. Analyses compared visits from January to June 2024 and January to June 2025. Main Outcomes and Measures:Outcomes included the number of in-person visits, in-person visit completion (show) rate, and telehealth visit proportion as a percentage of total outpatient visits. Mixed Poisson regression was used to estimate incidence rate ratios (IRRs) for completed outpatient visits and telehealth visit counts by month, comparing both proxy groups. Results:This study analyzed 184 541 outpatient visits in 2024 (48.7% females, 51% males, 0.2% other sex) and 182 573 outpatient visits in 2025 (49.8% females, 49.9% males, 0.3% other sex). During both 6-month periods, patients classified as likely undocumented had 15% higher in-person visit completion rates compared with patients likely with legal status (IRR, 1.15; 95% CI, 1.13-1.16). However, month-specific analyses found that in-person visit completion rates decreased in 2025 among likely undocumented patients, with decreases ranging from 5% to 12%, and significant decreases in March 2025 (IRR, 0.88; 95% CI, 0.83-0.93) and June 2025 (IRR, 0.93; 95% CI, 0.87-0.99) compared with 2024. The relative proportion of telehealth visits increased by 12% among likely undocumented patients between 2024 and 2025 (IRR, 1.12; 95% CI, 1.04-1.20) and decreased among patients likely with legal status (IRR, 0.95; 95% CI, 0.93-0.98). Among more than 367 000 visits, there was no clinically significant change in total visits for either group between 2024 and 2025 (IRR, 1.00; 95% CI, 0.99-1.02). Conclusions and Relevance:This study found that patients classified as likely undocumented had higher in-person visit completion rates than patients likely with legal status, but experienced month-specific decreases, which may correspond to increased immigration enforcement activities. Their increased telehealth use underscores its importance as a critical access pathway. Health systems leaders should anticipate shifts in care use and safeguard outpatient access by expanding telehealth supports for immigrant communities.
This Viewpoint uses dental care as a test case for whether rural health care reform translates into more reliable access.
Importance Patients frequently forgo filling prescriptions due to high out-of-pocket costs. Real-time prescription benefit (RTPB) tools that recommend available lower-cost, clinically equivalent medications to prescribing clinicians may increase the likelihood that patients fill their prescriptions. Objective To determine whether availability of an RTPB tool increases prescription fill rates. Design and Setting This post hoc analysis of a cluster randomized clinical trial included medical practices within an urban ambulatory clinical network randomized to the RTPB tool between January and December 2021. Outpatient prescriptions that were eligible for an RTPB recommendation during the study period were analyzed. Data analyses were performed from October 18, 2022, to August 9, 2024. Intervention An electronic health record–integrated RTPB tool that displays available lower-cost and clinically equivalent alternatives to the initiated prescription at the point of prescribing. Main Outcome and Measure The primary outcome measured whether a prescription was filled. Results Of 1 386 577 outpatient prescriptions at randomized practices during the trial period, 38 289 (2.8%) were included in the analytic sample. Across all orders, the availability of the RTPB tool did not impact the proportion of orders filled (54% and 55% in the control and RTPB groups, respectively; adjusted difference: 1.2 percentage points [pp]; 95% CI, −1.3 to 3.7 pp). However, in the quartile of drug classes with the highest out-of-pocket costs (average out-of-pocket cost for a 30-day fill of >$120.83), fill rates increased from 33% in the control group to 49% in the RTPB group (adjusted difference: 14.5 pp; 95% CI, 8.4-20.6 pp). Similar increases were not detected in lower-cost drug classes. Increases in fill rates within the highest out-of-pocket cost drug classes were largest for patients in the lowest-income communities served by the health system (30.3 pp; 95% CI, 19.5-41.1 pp) but not substantial in the highest-income communities (1.0 pp; 95% CI, −10.2 to 12.2 pp). Conclusions and Relevance In this post hoc analysis of a cluster randomized clinical trial, there was no change in overall prescription fill rates, but among high-cost drugs, the RTPB tool increased fill rates, particularly among patients from low-income communities. However, RTPB recommendations were made for a small proportion of orders, limiting the applicability of the findings to a narrow segment of the randomized population. Trial Registration ClinicalTrials.gov Identifier: NCT04940988
This cross-sectional study assesses changes maximum out-of-pocket costs in dual-eligible Medicare and Medicaid beneficiaries from 2017 to 2026 following the 2023 updated guidance for calculating maximum out-of-pocket spending.
