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. 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. 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. 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. 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.
We estimated the distributional impact of Vietnam-era G.I. Bill eligibility, a federal policy that subsidized education, impacting approximately 6 million veterans, on later-life memory levels and rate of age-related decline. We used Health and Retirement Study data (1998-2018) for men born 1947-1953 with at least one outcome assessment (n = 2337;15 433 person-waves). We proxied Bill eligibility using draft eligibility based on birthdate and self-reported veteran status. We used an algorithmic measure of memory as the outcome. We fit intention-to-treat and instrumental variables models at the mean and different outcome quantiles. We assessed effect modification using a childhood socioeconomic status index and self-reported race and ethnicity. Although imprecise, results are consistent with eligibility increasing memory levels but accelerating age-related decline, especially at lower quantiles. The magnitude of estimated effects were especially pronounced for men from low childhood socioeconomic backgrounds and Black men. For White men, eligibility was associated with uniformly accelerated decline across the distribution. Overall, our results paint a complex picture: eligibility may have improved overall memory score levels but also may have slightly increased the rate of age-related decline, especially among those with worse memory function. Further research is necessary to investigate the mechanisms by which such policies impact later-life memory.
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ObjectiveTo evaluate national billing patterns for adjunctive rhinoplasty during primary cleft lip repair and assess associated operative characteristics.DesignRetrospective database review.SettingAmerican College of Surgeons Pediatric National Surgical Quality Improvement Program, 2016-2021.Patients, ParticipantsPatients undergoing primary cleft lip repair identified using current procedural terminology (CPT) codes 40700-40702, stratified by use of additional rhinoplasty codes (30400-30462).InterventionsPrimary cleft lip repair with or without adjunctive rhinoplasty coding.Main Outcome Measure(s)Use of adjunctive rhinoplasty codes, operative and anesthesia times, surgeon specialty, patient characteristics, and temporal trends in coding.ResultsAmong 8836 patients, 32.9% (n = 2911) were billed adjunctive rhinoplasty codes, most commonly CPT 30460 (78.0%) and 30462 (16.2%). Cases billed with adjunct rhinoplasty codes were associated with longer operative (146.0 vs. 114.6 min; p < .001) and anesthesia times (208.8 vs. 172.4 min; p < .001), as well as a higher proportion of ASA class II patients (62.4% vs. 55.0%; p < .001). Plastic surgeons performed most primary cleft lip repairs (85%) and were more likely to bill adjunct rhinoplasty codes (p = .013).ConclusionsNearly one-third of primary cleft lip repairs include adjunctive rhinoplasty codes. Although comprehensive primary codes exist, differences in interpretation rather than evolving practice patterns may exist. Given the ongoing undervaluation of craniofacial procedures and limited coding mechanisms, clearer guidance is needed to better align billing with contemporary cleft surgical practice.
The prices of physician-administered drugs and biologics are coming under downward pressures from Medicare price negotiations, Most Favored Nation policies, and competition from biosimilars. These will reduce manufacturer sales revenue but potentially increase revenues for the hospitals that acquire these products at one price and are reimbursed by insurers at a higher price. This paper uses 2020-2024 Blue Cross Blue Shield insurer data on expenditures, pricing, and utilization to estimate the impact of manufacturer price decreases for 20 major biologics. Hospital margins for these 20 products increased from $2.37 billion in 2020 (55% of insurer expenditures) to $2.97 billion in 2024 (59%). A 20% manufacturer price reduction would increase hospital buy-and-bill margins to $4.84 billion, 52% of insurer expenditures, while a 40% reduction would increase hospital margins to $5.97 billion, 64% of insurer expenditures. The shift in insurer expenditures from drug manufacturers to hospitals is estimated to reduce research and development (R&D) investments between $282 and $564 million in 2028. A large share of insurer expenditures for physician-administered drugs and biologics are retained by hospital intermediaries rather than accruing to pharmaceutical manufacturers.
Switzerland has recently expanded financial support for family caregiving not through a dedicated carer allowance, but by routing payments through professional home care reimbursement. Following Federal Supreme Court rulings, relatives without nursing qualifications can be paid for reimbursable nursing tasks when contracted through an authorised home care provider. Market entry by for-profit agencies, combined with fee-for-service billing and substantial municipal residual cost financing, has contributed to rapid growth in billed home care hours and has exposed monitoring and accountability gaps. The first implementation package of the Nursing Care Initiative further reduced administrative barriers by allowing nurses to initiate and bill selected services without a physician order, shifting authorisation closer to the billing entity. The Swiss case highlights a design risk relevant beyond Switzerland: using unmodified professional reimbursement mechanisms to remunerate family carers imports volume incentives and can enable rent extraction unless task definitions, tariffs, transparency, and oversight are adapted. Policy options include a distinct reimbursement pathway for lay family carers, tighter operational definitions, claim identifiers to enable monitoring, and financing levers that protect carer pay while limiting agency margins.
Gender-based reimbursement disparities in orthopedic surgery remain poorly understood, particularly when accounting for practice composition and setting. The purpose of this study was to compare and evaluate gender-based differences in Medicare reimbursement and practice patterns among female and male orthopedic surgeons. A cross sectional analysis of public Medicare data from 2013 to 2021 was performed. Outcomes included annual Medicare payments, submitted charges, total services, service categories, and beneficiaries treated by orthopedic surgeons who bill Medicare. Univariate and multivariable analyses quantified differences in payment, practice volume and composition, geographic adjustment, and Current Procedural Terminology (CPT)-matched reimbursements. A total of 29,357 orthopedic surgeons (27,442 men and 1,919 women) billed Medicare fee-for-service during the study period. Female surgeons, on average, submitted 48.3% fewer total charges and received 44.1% lower annual Medicare payments per surgeon compared with male surgeons. These differences persisted after multivariable regression adjusted for practice metrics and excluded top and bottom earners. Female surgeons also billed fewer services, treated fewer beneficiaries, and submitted fewer unique CPT codes. However, payment disparities persisted even after matching surgeons by volume of services, beneficiaries, and years in practice. Male surgeons performed higher volumes of all 10 highest-paying orthopedic CPT codes. In CPT matched analyses, female surgeons received lower reimbursement per service than male surgeons performing identical procedures. These findings suggest that the observed gender-based disparities in orthopedic surgery Medicare reimbursement cannot be explained by differences in volume, procedural mix, or geographic practice cost. Instead, they likely reflect a combination of structural and behavioral mechanisms described in prior literature that may influence how access to clinical opportunities, referrals, and reimbursement practices unfold in surgical practices. Variations in coding practices may represent an important focus for future investigation and targeted educational initiatives. Level III, Retrospective Cohort Study. See Instructions for Authors for a complete description of levels of evidence.
Unintended pregnancy remains a significant public health challenge in the United States. In 2021, Arizona passed Senate Bill 1082 authorizing pharmacists to prescribe self-administered hormonal contraceptives, including oral contraceptive pills, the transdermal patch, and the vaginal ring. Successful implementation of such policies depends on pharmacists' willingness and ability to provide these services. The objectives of this study were to understand Arizona pharmacists' perceived benefits and barriers of providing direct pharmacy access to self-administered hormonal contraception, and to gauge their interest in receiving training on prescribing contraception at their practice. We conducted a cross-sectional survey of licensed Arizona pharmacists (n=7,972) in June 2022 through the Arizona Board of Pharmacy's electronic listserv. The survey assessed awareness of Senate Bill 1082, interest in prescribing and receiving training, and perceived benefits and barriers to providing contraceptive services. Chi-square analyses evaluated associations between demographic and practice characteristics and interest in prescribing. The study sample included 295 pharmacists (response rate 3.7%). A majority were aware of Senate Bill 1082 (61.9%) and expressed interest in prescribing hormonal contraception (57.2%), though only 40.3% agreed prescribing was currently feasible in their practice. Female pharmacists showed significantly greater interest than male pharmacists (62.5% vs. 47.6%, p=0.02). Top perceived benefits included increased contraceptive access (90.2%), reduction of unintended pregnancy (90.6%), and expanded scope of practice (84.4%). Top barriers were shortage of pharmacy technician staff (86.4%), liability concerns (88.7%), and lack of reimbursement (87.8%). Arizona pharmacists recognize the potential for pharmacist-prescribed hormonal contraception to improve access and reduce unintended pregnancy. However, substantial implementation barriers exist, particularly workforce shortages, liability concerns, and lack of reimbursement. Addressing systemic challenges through workforce development, clear liability guidance, and payment reform will be essential to translating legislative authorization into meaningful patient access.
Signed into law on July 4, 2025, the One Big Beautiful Bill Act (OBBBA) fundamentally changes the Supplemental Nutrition Assistance Program (SNAP), the largest food assistance program in the United States and a key support for maternal and child food and nutrition security. The OBBBA reduces SNAP eligibility, expands work requirements, eliminates nutrition education, prevents future benefit increases, and shifts significant costs to states. Combined, these changes may have a direct negative effect on women and children who rely on SNAP for adequate nutrition and may also reduce their access to other programs with automatic SNAP eligibility, namely the Special Supplemental Nutrition Program for Women, Infants, and Children and other child nutrition programs. The loss of this foundational public health nutrition infrastructure may negatively affect infant birth outcomes, child growth and development, and maternal morbidity and mortality. Although some state governments have implemented actions to reduce the effect of federal SNAP changes on maternal and child health, federal legislation to permanently reverse OBBBA SNAP provisions is critical to prevent short- and long-term harms. Adequately funded and accessible federal food and nutrition education programs have the potential to support the goals of the Make America Healthy Again initiative and the 2025-2030 Dietary Guidelines for Americans to support access to and consumption of whole, nutrient-dense foods and improve maternal and child health. Policy actions and funding levels for federal nutrition programs therefore should align with the stated goals of these initiatives. The purpose of this article is to describe OBBBA SNAP provisions and other related policy actions or inactions and their implications for maternal and child health in the United States. The purpose of this series is to critically examine emerging federal and state health policy changes and their implications for the health and well-being of women, childbearing families, and young children and to provide evidence-based analyses that inform the nurses who care for these populations. The author solicitation and preparation of each article are overseen by series coordinators Mindy B. Tinkle, PhD, RN, WHNP-BC, CNE, FAAN, associate professor, and Nick Edwardson, PhD, MS, associate professor, College of Nursing, University of New Mexico, Albuquerque, NM.
Sesh+ oral nicotine pouches (ONPs) are marketed as premium nicotine products and promoted regularly on social media platforms such as TikTok, Instagram, and X (formerly Twitter). In July 2025, Sesh+ ran 2623 ads on X; 561 (21.4%) explicitly promoted their 'clear' ONPs as being available for purchase in California using taglines like 'Clear in California', 'California Clear', and 'Shop Sesh Clear in California'. California Senate Bill 793 (SB 793) prohibits retail sales of tobacco products, including ONPs that impart a 'characterizing flavor'. Sesh+ markets its 'clear' ONPs on its website as 'flavorless', and the 'clear' pouches were present on California's Unflavored Tobacco List in January 2026. The 'Clear in California' advertising raises concerns about geographically targeted marketing that turns regulatory compliance into a promotional message. By explicitly incorporating a state name and the term 'clear', the ads may imply special approval or regulatory endorsement, confusing consumers. Combined with youth-oriented social media content, this strategy may increase appeal to young audiences. Sesh+ advertising illustrates how ONP companies may transform legal compliance into a marketing asset, underscoring the need for continued surveillance of geographically targeted nicotine advertising and its implications for perceptions of harm, product appeal, and tobacco initiation.
School nurses are vital advocates for student health, yet the New Mexico workforce has long faced staffing shortages and significant pay inequities. This article describes a successful policy advocacy campaign by the New Mexico School Nurses Association to achieve salary parity. By collecting and leveraging data, including statewide surveys and salary schedule audits, advocates demonstrated that school nurse compensation failed to match the state-mandated three-tiered pay scale guaranteed to teachers. This effort culminated in the passage of House Bill 195 in 2025, standardizing state-wide school nurse salary tiers and minimums. Subsequent legislation, House Bill 34 in 2026, refined licensure provisions for statewide implementation. This case study highlights the power of collective action, evidence-based arguments, and strategic partnerships with state agencies. The New Mexico experience provides a replicable model for school nurses to influence state-level policy and strengthen the school nursing workforce.
In 2024 and 2025, researchers investigated the breeding ecology of the Twite Linaria flavirostris in riparian shrubland habitats at an elevation of 3400 m in the northeastern Qinghai-Tibet Plateau. This species lays eggs from late June to mid-July, capitalizing on the region's brief warm season. Nests are typically open-cup structures built in Hippophae spp. shrubs. The population predominantly exhibits monogamous mating, with a mean clutch size of 4.7 ± 0.49 (3~5). Incubation is performed solely by the female and lasts 11.52 ± 1.65 days. Both parents provision the nestlings, and the nestling period lasts 12.43 ± 2.39 days. Morphological measurements of nestling body mass and external organs all fit well to the Logistic growth curve equation. By fledging, tarsus length and bill length reach over 90% of adult values, conferring substantial terrestrial mobility. However, flight-related feathers, primaries and rectrices, remain markedly underdeveloped compared to adults, resulting in extremely poor flight capability; further post-fledging development is thus required. Based on reproductive outcomes from this single breeding season, a total of 121 eggs were laid, of which 81 successfully hatched, and ultimately 79 fledglings survived to leave the nest. The overall hatching success was 66.94%, fledging success (among hatchlings) was 97.53%, and overall offspring survival (from eggs to fledglings) was 65.29%. The apparent nesting success rate was 76.0%, based on a total of 50 nests monitored over two years. Daily nest survival rates were estimated using Mayfield's method and program MARK, resulting in nest success probabilities of 0.587 and 0.219, respectively. Comparing populations across different geographic regions, the results indicate that Twites breeding in environments with higher levels of environmental stress produce smaller clutch sizes and larger eggs, and exhibit a prolonged nestling period. This life-history strategy likely represents an evolutionary adaptation to spatially variable environmental conditions.
This study explores pregnant Texans' expectations of and experiences with crisis pregnancy centers (CPCs) following implementation of Texas Senate Bill 8 (SB8), which in September 2021 prohibited abortions in Texas after detection of embryonic cardiac activity. We analyzed in-depth interviews with English-speaking Texans over 18 years of age who were or had recently been seeking abortion, focused on their care-seeking experiences, including with CPCs. Between October 2021 and August 2022, we recruited participants via online ads in Texas and flyers in abortion-providing facilities in seven other states. Using thematic analysis, we identified themes in CPC experiences and developed a CPC client typology. Of 120 participants, 36 described contact with CPCs; we categorize them into three client types, based on awareness of CPCs' anti-abortion position and expectations of CPC services. Fifteen were "deceived clients": unaware of CPCs' position, they contacted a CPC expecting abortion care or all-options counseling. Most remaining participants (n = 11) were "pragmatic clients": also unaware of CPCs' anti-abortion position, they expected only pregnancy information or support. A minority (n = 8) were "strategic clients"-aware of CPCs' anti-abortion position and therefore expecting only pregnancy information, they used CPC services strategically to determine eligibility for in-state abortion care or medication abortion. In addition to contacting CPCs because they were deceived or pragmatic, pregnant Texans considering abortion after SB8 drew on CPC services strategically. In an abortion-restrictive setting, pregnant people may try to use CPCs for free services that they cannot get as easily from licensed medical providers.
The 2018 Federal Farm Bill created a loophole allowing intoxicating hemp-derived tetrahydrocannabinol (THC) products to be manufactured and sold with limited regulations. Unless restricted by the state, these products are available across many retailer types. We assessed the likelihood of sales of hemp-derived THC products to underage individuals in one large city in Minnesota, USA which had a minimum purchase age of 21 but few other restrictions. We conducted pseudo-underage purchase attempts at establishments that reported or were observed carrying hemp-derived THC products in 2023. Buyers, 21 or older but judged by a panel to look aged 18-20, attempted to purchase hemp-derived THC products without age identification. We assessed whether the availability and purchase rate differed by community economic advantage and establishment type. Approximately one-third (149/452) of establishments carried hemp-derived THC products. The overall pseudo-underage sales rate was 56% (70/125). Establishments in areas of higher (vs. lower) economic advantage were more likely to carry hemp-derived THC products (40% vs. 30%) but less likely to sell to a pseudo-underage individual (49% vs. 68%). Compared to establishments that primarily sell non-age-restricted items (e.g., gas stations, grocery stores), establishments that primarily sell age-restricted products (liquor stores, tobacco stores, hemp-dispensaries) were more likely to carry these products (69% vs. 20%) but equally as likely to sell to pseudo-underage individuals (54% vs. 57%). Our results suggest that underage people could easily access hemp-derived THC products. It is imperative that these products are considered in assessments on availability of cannabis.
This article aims to explore the ethical and legal considerations involved in the assessment of mental capacity by community nurses in the UK. Grounded in the principles of the Mental Capacity Act 2005, the article explores the practical challenges community nurses face when applying legal frameworks in varied clinical contexts, including home visits, remote consultations and multidisciplinary care. Key themes addressed include the role of consent, safeguarding responsibilities, fluctuating capacity in chronic illness, family and professional disputes and supported decision making for individuals with learning disabilities. The article also highlights how legal instruments such as the Human Rights Act 1998, Equality Act 2010, Care Act 2014 and Health and Social Care Act 2012 underpin safe and lawful practice. It also explores the implications of emerging legislation, such as the Data Protection and Digital Information Bill and regulatory guidance, on remote assessments and digital ethics. The author looks at cultural and religious considerations with attention to preventing bias and promoting equity. The article draws on recent literature and case law, including Re C (Adult: Refusal of Treatment), to illustrate the complex association between professional judgement and patient autonomy, while upholding healthcare professionals' legal duties. By providing a structured and comprehensive review, this article aims to equip community nurses with the legal literacy and ethical insight necessary to navigate capacity assessments confidently.
This work presents the development and validation of a modular and programmable breathing phantom station designed for accelerated degradation testing of industrial respirator filters. The system replicates human respiratory patterns using a mechanical ventilator and a custom-built humidification unit, enabling controlled exposure of filters to respirable dust particles (≤10 µm) within a sealed contamination chamber. Filter saturation is assessed through pre- and post-exposure weight measurements, providing a direct and quantifiable evaluation method. Experimental validation was conducted through an accelerated degradation test using two filter samples to assess reproducibility. The experiment used a particulate concentration of 104 mg/m3, corresponding to 10.4 times the OSHA permissible exposure limit, allowing accelerated testing under physiologically realistic breathing conditions. Over a one-week exposure period, P100 filters exhibited a progressive mass increase of approximately 1.3 g from an initial weight of 13 g, reaching a clear gravimetric saturation plateau. Results demonstrated strong reproducibility across different respiratory profiles and alignment with manufacturer-defined saturation limits. The platform provides a scalable and cost-effective tool for respiratory filter testing, with potential adaptability to various respirator designs and materials, filter types and airborne contaminants. Full hardware documentation, including schematics, the bill of materials, and the control procedure, is made available to support replication and further innovation within research and occupational health and safety.