Importance:Cross-sectional studies indicate that out-of-pocket (OOP) health care costs strain household finances, but few studies have examined the risk of incurring burdensome health care spending longitudinally among individuals in the US. Objective:To assess burdensome OOP health care costs (and care foregone due to cost) over a 4-year period. Design, Setting, and Participants:In this cohort study, data were analyzed on respondents to the 4-year longitudinal Medical Expenditure Panel Surveys (MEPS), a nationally representative household survey of the US noninstitutionalized population conducted from 2018 to 2022. Analyses were performed from November 2024 to October 2025. Main Outcomes and Measures:Primary outcomes included 4 cost-related outcomes: cost burden, defined as individual annual OOP medical spending greater than 10% of family income (>5% for low-income individuals); catastrophic cost burden (CCB) defined as OOP spending greater than 40% of postsubsistence income; foregone care due to cost; and family-level cost burden. Risk was assessed using time-to-event analyses, overall and among subgroups, eg, baseline chronic disease, hospitalization, and uninsurance, and death during the study period. Results:Among 12 645 MEPS respondents, 74.6% (95% CI, 73.4%-75.8%) were aged 18 years or older and 50.6% (95% CI, 49.7%-51.6%) were female individuals (weighted); among adults, 50.3% (95% CI, 48.6%-52.0%) had a chronic disease, 7.9% (95% CI, 7.2%-8.7%) were hospitalized, and 2.3% (95% CI, 2.0%-2.6%) died. During year 1, 6.5% of adults experienced cost burdens (and 3.5% CCB); 17.4% (and 9.9% CCB) experienced these outcomes (respectively) at least once over 4 years. Overall, 24.7% of US individuals lived in families experiencing cost burdens over 4 years, and 11.2% lived in families experiencing CCBs. Overall, 26.7% of adults experienced either foregone care due to cost or cost burden over 4 years. Lower income, having no insurance, hospitalizations, and chronic disease were each associated with higher cost burden. Overall, 53.2% of decedents experienced cost burdens in 1 to 4 years before death. Conclusions and Relevance:This cohort study found that the US health care system imposes cost burdens on a larger share of the population than suggested by cross-sectional analyses, and most individuals in the US will experience such burdens during their lifetimes. Policies that reduce OOP costs might improve the well-being of individuals in the US.

Policy Points The One Big Beautiful Bill Act (OBBBA) may impose the largest coverage losses in US history, causing the number uninsured to rise by 55% in the coming decade. We examined four prior coverage contractions-Reagan-era Medicaid cuts, the 2005 TennCare disenrollment, 2019 Arkansas work requirements, and the Medicaid Unwinding-to shed light on the OBBBA's impacts. These suggest that most who lose Medicaid do not find alternative coverage, and that states are unlikely to compensate for federal cuts, findings that run counter to some assumptions adopted by the Congressional Budget Office in predicting the impacts of Medicaid cuts. Studies of coverage contractions complement data from coverage expansions in predicting worse health care access, household finances, and health for needy individuals due to the OBBBA. Studies also suggest that the magnitude of harms from contractions may exceed that suggested by expansions. CONTEXT:The so-called One Big Beautiful Bill Act signed into law by President Trump on July 4, 2025 will cut $1 trillion from federal health care programs over the coming decade and cause 10 million individuals to become uninsured according to the Congressional Budget Office. Most analyses of the bill's impacts have assumed they would be the inverse of those documented from previous coverage expansions. An examination of past coverage cuts might yield additional insights into the probable impacts of this legislation on the medical care and health of the needy. METHODS:We reviewed studies of four prior large scale coverage contractions: Reagan-era Medicaid cuts, the 2005 Tenncare Disenrollment, the 2019 implementation of work requirements in Arkansas, and the postpandemic "Unwinding" of Medicaid. FINDINGS:The experience of these prior coverage contractions complements evidence from analyses of coverage expansions in predicting that widespread insurance loss will lead to a reduction in care utilization, an increase in household financial strain, and worsened physical and mental health for low-income individuals. These coverage contractions additionally suggest that most who lose Medicaid coverage will not find alternative coverage; that work requirements will impose burdensome administrative costs on states; that states are unlikely to offset reductions in federal Medicaid funding with internal funds; and that the second-order effects of coverage losses may, in some instances, be greater (in magnitude) than the benefits seen after coverage expansions. CONCLUSIONS:Cuts to federal health care programs will produce sharp contractions in public coverage that will worsen existing problems in US health care such as insurance churn, degrading care, and worsening health inequality. While states may take some steps to mitigate harmful impacts, better protection of the medically needy would require repeal of the legislation, while full protection would require universal, seamless coverage.

Importance:The US has higher mortality rates than other high-income countries (HICs). However, a comprehensive analysis of excess US deaths encompassing all leading causes of death over the past 2 decades is currently lacking. Objective:To investigate causes of death responsible for excess US mortality compared with other HICs and how the causes of death involved in this US mortality disadvantage have changed over time. Design, Setting, and Participants:This repeated cross-sectional study included mortality data from the World Health Organization Mortality Database spanning 1999 to 2022 for the US and 17 other HICs. Data were analyzed from September 2023 to December 2025. Exposures:Residing in the US vs another of the included HICs. Main Outcome and Measures:The main outcome was excess US mortality in each year due to specific causes of death. Differences between the US and other HICs were quantified for each cause of death as (1) excess US deaths (ie, absolute difference between observed deaths and deaths expected if US death rates equaled the rates of other HICs); (2) years of life lost (YLL) resulting from excess US deaths; and (3) mortality rate ratios (ie, ratios of observed to expected age-standardized death rates). Results:A total of 63 547 318 deaths occurred in the US from 1999 to 2022 (50.4% among males; mean [SD] age at death, 73.2 [18.5] years). In this period, 12 675 646 excess US deaths occurred, increasing from 346 166 in 1999 to 905 159 in 2022. Circulatory diseases were the leading cause of excess US deaths every year except 2010, increasing after 2001 for ages 45 to 64 years and after 2009 for ages 65 years or older. Together, circulatory and metabolic diseases accounted for 52% of excess US deaths in 2022. Excess US deaths due to drug poisonings, alcohol, and suicide increased from -5762 in 1999 to 131 151 in 2022; together, these 3 causes accounted for 24% of the increase in excess US deaths overall and most of the increase in excess US deaths for individuals aged 0 to 44 years. In 2022, deaths from drug poisonings were 7.48 times higher in the US than in other HICs. In 2020 and 2021, 19% and 23% of excess US deaths, respectively, were attributed to COVID-19, but excess US deaths from other causes also increased. Conclusions and Relevance:In this repeated cross-sectional study of cross-national mortality, the US had substantially higher death rates than other HICs between 1999 and 2022, despite having similar access to advanced medical technology. Many of these excess US deaths could likely be avoided by adopting health and social policies that have benefited other HICs. These descriptive findings should be interpreted in light of uncertainty arising from differences in death coding, data completeness, and other aspects of data comparability across countries.

Objectives. To describe health care‒related educational divides in 2 dimensions-outpatient care utilization and medically preventable deaths-over the past 25 years. Methods. We examined education-based disparities in ambulatory care utilization by analyzing data on 476 277 respondents aged 25 years or older to the 1996-2022 US Medical Expenditure Panel Survey, and in deaths potentially preventable by medical care (defined by International Classification of Diseases, 10th Revision, code) from 26 092 720 death certificates of individuals aged 25 to 74 years in the United States from 2001 to 2023. Results. In 1996, the share of adults with zero provider visits was higher among those without (26.4%; 95% confidence interval [CI] = 25.3, 27.5) than with (20.2%; 95% CI = 18.5, 22.0) a bachelor's degree, a gap that widened to a nearly 2-fold difference by 2022; the gap in the proportion with no doctor visit also widened. Disparities in health care use were larger after adjustment for health factors. Separately, we observed large and growing education-based gaps in age-adjusted health care‒amenable mortality. Conclusions. Education-based disparities in ambulatory health care utilization have grown since 1996, as have medically preventable deaths. Public Health Implications. Improved health care access for less-educated Americans might help address widening disparities in ambulatory health care use and, potentially, health outcomes. (Am J Public Health. 2026;116(5):692-701. https://doi.org/10.2105/AJPH.2025.308373).

Cold-related illnesses (CRIs) are preventable yet often deadly. Using twenty-five years of data from the National Inpatient Sample (1998-2022), we assessed nationwide trends in CRI hospitalizations and concomitant alcohol use, substance use, and mental health disorders and housing insecurity. We identified 345,314 (weighted) CRI hospitalizations and found that age- and sex-adjusted rates tripled from 42.0 to 122.5 per 100,000 hospitalizations. CRI inpatients were more likely than others to die during hospitalization, live in high-poverty ZIP codes, be publicly insured or uninsured, and have behavioral health conditions and housing instability. These findings highlight the rising and unequal toll of CRIs in the context of social instability and increasingly severe cold events associated with climate change. Expanded access to behavioral health treatments, increased subsidies for home heating, investments in affordable and supportive housing and shelter capacity, and public health measures to increase resilience to extreme weather events could reduce CRI morbidity and mortality.

BACKGROUND:Percutaneous coronary interventions (PCI) can be lifesaving for patients with acute coronary syndromes but of lower value for patients with stable coronary artery disease (CAD). Previous studies suggest that larger provider supply drives higher healthcare utilization. Whether this is true for lower-value PCI is unknown. OBJECTIVE:To examine the association between the regional supply of PCI-performing physicians and PCI use and lower-value use. DESIGN:Cross-sectional. SETTING:100% Medicare fee-for-service (FFS) claims and Medicare Advantage encounter data, linked to publicly available sources of population and hospital data. PARTICIPANTS:All Medicare FFS and MA beneficiaries undergoing PCI at US hospitals, 2019-2021. MEASUREMENTS:Our exposure was the supply of PCI-performing physicians per million population in the hospital-referral-region (HRR). Our primary outcome was lower-value PCI provision defined as the share of all PCIs performed for stable CAD at the hospital-level, unadjusted and with multilevel linear regression adjustment for hospital and regional-population factors. We also examined both PCI use and lower-value use at the regional (HRR) level. RESULTS:Our final dataset included 1,580 hospitals across 306 HRRs with 5,505 PCI-performing physicians. In our primary, hospital-level analysis, the lower-value PCI provision rate averaged 17.3% among hospitals located in HRRs in the lowest quintile of PCI provider density and 22.6% among hospitals in HRRs in the highest quintile. In our fully adjusted model, hospitals in the highest provider density quintile had a 5.77 percentage point higher lower-value provision rate than those in the lowest quintile (95% CI 3.70, 7.84; p < 0.01). In our HRR-level analysis, both the total number of PCIs/beneficiary and lower-value PCIs/beneficiary rose with increasing regional PCI-provider density. CONCLUSIONS:Among Medicare beneficiaries, the regional supply of PCI providers correlates with PCI overall and lower-value use. These findings support a role for health planning efforts to align workforce supply with community health needs to constrain both costs and the provision of low-value care.

This cross-sectional study examined whether parental job lock and other financial and employment factors are associated with access to care for children with cystic fibrosis.

This Viewpoint discusses the collapse of the Steward Health Care system as a case in point of the salience of proprietorship in health care, the problem of private equity firms’ business models emphasizing short-term gains, and the conflict between financial ambition and clinical mission.

Millions of Americans have medical debt and/or defer care due to cost. Few studies have examined the association of such health-related financial problems with sexual orientation or gender identity, and whether state-level policies protecting sexual and gender minority (SGM) people affect disparities in such problems. To examine the relationships between SGM status, state-level SGM protections, and health-related financial problems. Cross-sectional analysis. Nationally-representative sample of U.S. adults in the 2021 National Financial Capability Study. Prevalence of medical debt and/or deferred care; adjusted odds ratios (aORs) by SGM status and residence in a state with fewer SGM protections. Of 25,170 survey respondents, 3.7

Recent wars in Ukraine and Gaza, prosecuted with U.S. backing, have caused massive losses of life and, in Gaza, destruction of medical facilities. We performed searches using PubMed and journal websites to assess how many items addressing these wars have appeared in the leading U.S. and U.K. medical journals. We find that the U.S.-based journals (especially the New England Journal of Medicine) have carried few or no items on these wars; the U.K.-based journals have published many more.

BACKGROUND:Many healthcare workers, particularly women of color, are poorly paid, and even among physicians, women and some minoritized groups earn less. Earnings inequalities are generally smaller in the public sector and might be attenuated in the Veterans Health Administration (VHA). OBJECTIVE:To compare earnings and earnings disparities among VHA and non-VHA healthcare workers. DESIGN:Cross-sectional analysis of 2018-2022 American Community Survey data. PARTICIPANTS:Personnel in hospitals or outpatient care settings (n=591,265; weighted n=12,717,305/year, including n=358,118 VHA employees). MAIN MEASURES:Annual earnings overall and for individual occupation groups among VHA and non-VHA personnel; and gender-based or race/ethnicity-based earnings disparities assessed using linear regressions controlled for annual work hours and occupation. KEY RESULTS:Mean earnings were higher in VHA than non-VHA settings; $88,964 (95% CI $86,373-89,754) vs. $81,125 ($80,718-$81,532), and pay inequalities were smaller in the VHA. Earnings in the VHA were lower for a few higher-income occupations, including physicians, whose earnings averaged $255,158 [95% CI 244,733-265,583] in the VHA vs. $286,090 [95% CI 283,613-288,567] in non-VHA settings, a difference (after control for annual work hours) of $26,702 [95% CI 15,691-37,713]. Gender- and race-based disparities were present but smaller in VHA than non-VHA settings. Adjusted for work hours and occupation, the pay disparity between women and men was $12,215 [$9151-$15,279] in the VHA and $26,859 [$25,981-$27,737] in non-VHA settings (p for interaction <0.0001). The adjusted earnings gaps for non-Hispanic Black vs. non-Hispanic white personnel were $5496 [$2384-$8608] vs. $9111 [$7825-$9093] (p for interaction = 0.015). Hispanic personnel earned less than non-Hispanic white personnel in both settings, and disparities were similar. CONCLUSIONS:Although physicians earn somewhat less in the VHA than in other settings, overall VHA personnel earn about 10% more on average, overall earnings inequalities are smaller, as are earnings disparities for women and Black personnel.

Recent wars in Ukraine and Gaza, prosecuted with U.S. backing, have caused massive losses of life and, in Gaza, destruction of medical facilities. We performed searches using PubMed and journal websites to assess how many items addressing these wars have appeared in the leading U.S. and U.K. medical journals. We find that the U.S.-based journals (especially the New England Journal of Medicine) have carried few or no items on these wars; the U.K.-based journals have published many more.

Rationale: Early-life exposures may precipitate asthma, but their contribution to disparities in asthma is less clear. Objective: To elucidate racial, ethnic, and socioeconomic status (SES) disparities in the age trajectory of asthma burden among U.S. children. Methods: We analyzed three datasets: 1) 2016-2021 National Children's Health Survey (n = 223,551), 2) 2015-2017 Child Asthma Call-Back Survey (n = 4,289), and 3) 2018-2019 National Inpatient Sample (n = 23,713 children with asthma). We examined cumulative asthma prevalence by individual year of age and children's race and ethnicity or SES (National Children's Health Survey); mean age at asthma diagnosis by race and ethnicity and SES, unadjusted and adjusted for confounders (Asthma Call-Back Survey); and asthma hospitalization rates overall and per child with asthma by individual year of age and race and ethnicity (National Inpatient Sample). Results: Among White children, cumulative asthma prevalence increases gradually through childhood to 6.6% at age 5 years and 16.1% by age 17 years. Prevalence increases more sharply in early childhood among Black children, reaching 17.6% at age 5 years (risk ratio, 2.6; 95% confidence interval, 1.9-3.8), but plateaus after age 9 years, with a consequent decrease in Black-White relative disparities into adolescence. Disparities according to SES follow a similar trajectory, emerging early and subsequently narrowing. Similarly, Black, Hispanic, and low-income children with asthma are diagnosed at an earlier age than White (or high-income) children. The asthma hospitalization rate increases in the first years of life among all children, but most rapidly among Black children, with a peak absolute Black-White gap at age 4 years; the relative gap remains wide throughout childhood and peaks at age 10 years. However, per child with asthma, relative White-Black disparities in hospitalizations increase through age 15 years. Conclusions: Disparities in asthma prevalence emerge in early childhood and then narrow, suggesting that reducing early-life adverse environmental exposures may be key to asthma prevention. Policies to improve the social determinants of health during gestation and childhood, e.g., environmental equity and family income support, are needed.

Importance:Mortality of American Indian and Alaska Native (AI/AN) persons is known to be high but may be underreported in routine vital statistics. Objective:To estimate age-specific mortality rates and life expectancy for non-Hispanic AI/AN individuals and other racial and ethnic groups, using self-identified race and ethnicity data in a national cohort, circumventing errors due to racial misclassification on death certificates. Design, Setting, and Participants:This longitudinal cohort study used data from the Mortality Disparities in American Communities (MDAC) study, a nationally representative cohort created through the US Census Bureau's linkage of the 2008 American Community Survey (ACS) with death records from the National Vital Statistics System through 2019. The cohort included 4 135 000 ACS respondents, including 30 500 who self-identified as AI/AN (alone) and 58 000 who self-identified as AI/AN alone or in combination with another race (AI/AN-AiC). Exposure:Self-identified race and ethnicity. Main Outcomes and Measures:Age-specific mortality rates and life expectancy, estimated using continuous time, nonparametric period survival curves by self-identified race and ethnicity; comparisons to estimates from the US Centers for Disease Control and Prevention (CDC) WONDER database based on race and ethnicity reported on death certificates; and classification ratios for self-reported vs death certificate-recorded AI/AN race among decedents in the MDAC. Analyses were stratified by time period, sociodemographic factors, and cause of death. Results:Life expectancy of self-identified AI/AN individuals was 72.7 years (73.9 for AI/AN-AiC individuals), 6.5 years less than the US-wide average of 79.2 years. The AI/AN vs US average life expectancy gap widened from 4.1 years in 2008 to 2010 to 8.0 years in 2017 to 2019. Among self-identified AI/AN and AI/AN-AiC decedents, only 59.0% and 39.8% had AI/AN race reported on their death certificates, yielding classification ratios of 1.26 and 1.81, respectively. AI/AN race was most frequently underreported for heart disease and cancer deaths and less frequently for deaths from violence, drugs, and alcohol. In CDC WONDER data (based on race and ethnicity from death certificates), age-standardized mortality was 5% higher for AI/AN individuals than the US average (1067 vs 1016 deaths per 100 000). In MDAC data, mortality for self-identified AI/AN individuals was 42% higher (1420 vs 999 deaths per 100 000). The AI/AN life expectancy gap was 2.9 times larger in the MDAC than in unadjusted official statistics. Conclusions and Relevance:This longitudinal cohort study found that large life expectancy differences between AI/AN individuals and other US residents have been underestimated due to racial misclassification on death certificates, resulting in the statistical erasure of Indigenous people in routine vital statistics.

This cohort study examines trends in excess deaths in the US before, during, and after the COVID-19 pandemic.