Childhood vaccination rates have declined in many US states, contributing to outbreaks of vaccine-preventable diseases and raising concerns about policy effectiveness amid growing vaccine hesitancy. To evaluate the association between state repeal of nonmedical vaccine exemptions and kindergarten vaccination rates. This cross-sectional study used annual state-level kindergarten vaccination and exemption data from the Centers for Disease Control and Prevention for school years 2011 through 2023. A staggered difference-in-differences design compared states that repealed nonmedical exemptions with states that maintained such policies. The study included kindergarten students in US public and private schools across 37 to 43 states, depending on the outcome measure. Total repeal of nonmedical vaccine exemptions in California (2015), New York (2019), Maine (2019), and Connecticut (2021). Partial repeal in Vermont (2015) and Washington (2019) was analyzed separately. State-level kindergarten vaccination rates for diphtheria-tetanus-acellular pertussis (DTaP), hepatitis B, measles-mumps-rubella (MMR), and poliovirus (polio) vaccines; rates of medical and nonmedical exemptions. Among 4 states with total repeal affecting approximately 2.8 million kindergarten students, repeal of nonmedical exemptions reduced overall exemption rates by 3.2 (95% CI, 1.9-4.4) percentage points within 3 years. Compared with nonrepeal states, vaccination rates rose by 4.1 (95% CI, 3.3-4.9) percentage points for DTaP, 2.8 (95% CI, 2.1-3.5) percentage points for hepatitis B, 4.0 (95% CI, 3.1-4.9) percentage points for MMR, and 3.8 (95% CI, 2.9-4.6) percentage points for polio. Minimal substitution toward medical exemptions occurred, an increase of only 0.4 (95% CI, 0.04-0.7) percentage points. Partial repeal of nonmedical exemptions demonstrated smaller, less persistent increases in vaccination rates. State repeal of nonmedical vaccine exemptions was associated with increased kindergarten vaccination rates with minimal substitution toward medical exemptions. These findings suggest that nonmedical exemption repeal played a role in maintaining vaccination coverage in repeal states during a period of heightened vaccine hesitancy.
While repeal of universal motorcycle helmet laws has been linked to increased crash-related morbidity, prior work evaluating the impact of repeal on crash-related costs is primarily limited to pre-post differences that neglect to account for underlying temporal trends. In this context, we sought to evaluate the impact of universal motorcycle helmet law repeal on crash-related costs using multiple-group interrupted time series methods. We evaluated the impact of Michigan's universal motorcycle helmet law repeal on inflation-adjusted inpatient costs associated with motorcycle crashes. We used data from the Healthcare Cost and Utilization Project State Inpatient Databases from 2009 to 2015. Michigan's repeal occurred in April 2012. We performed a multiple-group interrupted time series analysis comparing Michigan and four control states chosen for geographic and sociodemographic similarity. 19,685 patients age ≥21 years were identified, of whom 5,280 were from Michigan. Universal motorcycle helmet law repeal was associated with a $5,785 (95% CI $3,022-8,548, p<0.001) increase in inpatient costs per motorcycle crash patient in Michigan. This corresponded to a 26% increase in average cost per patient and $4.5 million/year excess annual expenditure over the study period. There was no association between repeal and cost change in the control group ($47, 95% CI -$1,094-1187, p=0.9). Universal motorcycle helmet law repeal is associated with a 26% increase in crash-related inpatient costs. As policy repeal has occurred in 33 US states, a substantial portion of nationwide medical costs associated with motorcycle crashes may be potentially preventable.
Noneconomic damage caps, a form of medical malpractice law, remain controversial, as several states have enacted such laws since 2010, whereas others have repealed them. The clinical consequences of repealing these caps are poorly understood, and understanding these associations can inform the ongoing debate about medical malpractice reform. To examine whether repealing noneconomic damage caps is associated with changes in maternal care and infant health outcomes. This cross-sectional study adopted a difference-in-differences design, comparing between 2 treated states (Georgia and Illinois) that repealed their noneconomic damage caps in 2008 to 2009 and 16 control states that retained their caps during the entire study period between 2005 and 2019. The Centers for Disease Control and Prevention All-County Natality Files were used to estimate multivariate linear models, controlling for maternal and infant characteristics and county-level and state-level covariates. Estimates were stratified by county rurality and birth risk conditions. Data were analyzed from April 1, 2024, to April 9, 2026. The primary outcomes were 4 measures of maternal care and procedures (physician-attended births, inductions, cesarean delivery births, and prenatal visits) and 3 birth outcomes (low Apgar score, low birth weight, and preterm births). Difference-in-differences models with 2-way fixed effects were estimated, and linear models for the study outcomes were specified. The sample included 20 426 267 live births (mean [SD] gestational age, 38.55 [1.35] weeks). Compared with their counterparts in the control states, rural counties in the treated states experienced a statistically significant increase of 2.92 percentage points (pp) (95% CI, 1.40-4.50 pp; Bonferroni-adjusted P = .01) in physician-attended births. The increase held for both low-risk (3.10 pp; 95% CI, 1.33-4.90 pp; P = .004) and high-risk (2.56 pp; 95% CI, 0.77-4.34 pp; P = .01) births in rural counties. There was no difference between treated and control states for physician-attended births overall or in urban counties. No statistically significant associations were observed for cesarean deliveries, inductions, prenatal visits, or infant health outcomes after adjusting for multiple comparisons. In this cross-sectional study of 20 426 267 live births across 18 states, repealing noneconomic damage caps was associated with increased physician-attended births in rural counties but was not associated with statistically significant changes in other maternal care measures or infant health outcomes. These findings suggest that increased liability risk after repealing the caps may shift the composition of birth attendants in resource-constrained settings without demonstrable changes in infant health.
Israel's sugar-sweetened beverage (SSB) tax, combining ad-valorem and tiered components, was implemented in January 2022 and repealed after one year. We evaluated the effect of tax implementation and repeal, on beverage price and sales. A longitudinal analysis using national sales data. Beverages were categorized by sugar content and volume into 6 beverage groups: Large non-taxed, large reduced-tax, large full-tax, small non-taxed, small reduced-tax and small full-taxed beverages. Changes in price and sales across three periods (pre-tax, tax and post-tax) were assessed between groups using Welch ANOVA test (Games-Howell post-hoc analysis, Bonferoni adjustment), and the linear mixed-effects model with restricted maximum likelihood estimation. With implementation of the tax, the prices of all beverage categories increased by 3.03-38.89 % and remained high after tax repeal by 6.8-13.63 %, compared to pre-tax levels. Negative correlations between the change in beverage price and sales were observed during the tax (r = -0.54, p < 0.001) and post-tax (r = -0.29, p < 0.001) periods. A price increase of ≥17 % was associated with significant sales declines during the year of the tax. Sales of large reduced-tax beverages declined by -30.7 % and those of large full-taxed beverages by -24.1 % following tax implementation. After tax repeal, sales levels gradually increased compared to those during the tax period, but remained below pre-tax levels by -24 % and -13 %, respectively. Small-taxed beverages showed no significant change in sales between study periods. The Israeli SSB tax implementation and repeal, provides critical insights regarding the significant effectiveness of this public health policy. The tax led to a significant increase in the price of all beverage categories, and reduced sales of large-taxed beverages, which contribute the vast majority of national beverage sales. Tax repeal was followed by a gradual rise in sales of taxed beverages, having a potentially negative effect on public health. An effective policy should consider higher tax rates for smaller packaged beverages. Future studies should address longer follow-up and assessment of individual purchase and consumption practices.
A minimum unit price (MUP) of AUD$1.30 per standard drink was implemented in 2018 in the Northern Territory (NT), Australia, to reduce the availability of cheap alcohol. Despite evidence of its efficacy in decreasing alcohol consumption and harms, the MUP was repealed on 1 March 2025. This study aimed to determine the immediate impacts of the MUP repeal on the price of off-premises (i.e. takeaway) alcohol in Darwin, NT, assessing the proportion of products available <$1.30 per standard drink after the repeal in March 2025, identifying whether these products were pre-existing or new to market, and analysing any broader shifts in the price distribution across all alcoholic products that could be attributable to the repeal. Observational study of all alcoholic products available from three large alcohol retailer websites. Darwin, NT, between October 2024 and March 2025. Price per standard drink was estimated, and fixed-effects panel quantile regression was used to test for price differences. Within one month of the repeal, no beer or spirits, 5.1% of all wine and 2.5% of all ciders were available <$1.30 per standard drink, including 67.6% of the 37 wine products in vessels ≥1 L. Of the products identified at <$1.30 per standard drink, most had been available in previous months (i.e. not new or restocked). Quantile regression results showed a downward shift in price across the market for all product types, including beer and spirits, which were priced substantially above the $1.30 threshold at all percentiles. The largest reductions were observed for cheaper spirits, beer, cider and wine ≥1 L, ranging from $0.08 at the 20th percentile for spirits to $0.48 for wine ≥1 L at the 10th percentile. The minimum unit price repeal in Northern Territory, Australia, in March 2025 resulted in an immediate increase in the availability of cheap alcohol products and a downward shift in the overall price of alcohol in the off-premises market, particularly for lower-priced products.
For over a decade, New Zealand pursued a comprehensive reform of its outdated medicines legislation, culminating in the passage of the Therapeutic Products Act 2023 (TPA) in 2023. In a policy reversal, the Act was repealed by a new government in 2024. This study provides an analysis of this policy cycle to understand the drivers of the reform, its subsequent repeal and the implications for future health policy. We take a political economy perspective, foregrounding health policy instability and its consequences for patients, clinicians and Māori health interests. We conducted a qualitative documentary policy analysis of 25 key government and stakeholder documents, including legislation, regulations, cabinet papers and select committee reports with their submissions. We employed a framework method for a systematic thematic analysis of the corpus to map and interpret the policy narratives. The impetus for the TPA was a consensus that the Medicines Act 1981 and its associated regulations from 1984 and 1985 were "no longer fit for purpose". The repeal was driven by an ideological shift, reframing the TPA as an unacceptable "regulatory burden". This has tangible consequences, including the loss of a pre-market approval framework for medical devices and the erasure of legislative provisions designed to protect and recognise Rongoā Māori (traditional Māori healing). The TPA policy cycle is a case study in the fragility of evidence-based health reform. It demonstrates that without a durable, cross-party political consensus, long-term policy projects are highly vulnerable to being dismantled by short-term shifts in political ideology, with downstream harms from regulatory instability. It also illustrates how a targeted "micro‑reform" can generate outsized system‑level consequences.
Evaluation of New York State (NYS) Senate Bill 2994A repealing school-entry nonmedical vaccine exemption options suggests that the law was effective to increase school vaccine coverage; however, the law's impact on homeschooling has not been examined. Our objective was to evaluate the impact of NYS Senate Bill 2994A on homeschooling prevalence. We conducted a population-based cohort study with interrupted time-series analyses to estimate homeschooling prevalence differences (PD) comparing the time periods before (referent) and after NYS Senate Bill 2994A. The study cohort comprised school districts submitting all annual enrollment and homeschooling reports for the 2014-15 through 2019-20 school years. Crude and adjusted PDs accounting for longitudinal homeschooling trends were estimated at the population-, district-, and county-levels. Analyses were conducted in January 2025. Among 685 (99.3%) NYS school districts, NYS Senate Bill 2994A was associated with a 0.1% (95% CI: 0.1%-0.1%) increase in homeschooling prevalence among New York City (NYC) students and a 0.3% (95% CI: 0.2%-0.3%) increase among students outside of NYC, after adjustment for longitudinal trends. At the district-level, the law was associated with a mean 0.4% (95% CI: 0.3%-0.5%) increase in homeschooling prevalence among non-NYC schools. Spatial variation in crude homeschooling PDs was observed in county-level estimates (range: -0.3% to 1.5%; interquartile range: 0.2% to 0.5%). We found that NYS Senate Bill 2994A was associated with small, but significant increases in homeschooling prevalence. These results suggest a small number of un(der)vaccinated students may have disenrolled from traditional "brick-and-mortar" schools to avoid compliance with the law.
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In June 2023, the US Supreme Court's decision in Students for Fair Admissions v. Harvard University effectively overturned affirmative action, raising concerns about the future of diversity in medical education. A diverse physician workforce is crucial for advancing health care equity and improving patient outcomes. To evaluate the association between the Supreme Court's ruling and the racial and ethnic composition of students matriculating into Doctor of Medicine (MD) and Doctor of Osteopathic Medicine (DO) programs. Cross-sectional analysis of comprehensive publicly available data on medical school applications and matriculation by race and ethnicity from 2020 to 2024. Data were obtained from the Association of American Medical Colleges (AAMC) and the American Association of Colleges of Osteopathic Medicine (AACOM) to compare across MD and DO programs. Five application cycles were analyzed, with 4 representing preruling trends. Change in the racial and ethnic composition of matriculating medical students following the Students for Fair Admissions v. Harvard University decision. From 2020 to 2025, there were a mean (SD) of 55 037 (4315) applicants and 22 750 (349) matriculants to MD institutions and 214 163 (17 243) applicants and 9019 (274) matriculants to DO institutions. Significant disparities in application and matriculation patterns were observed across both program types, with persistent underrepresentation among American Indian or Alaska Native, Black, Hispanic, Native Hawaiian, and multiracial applicants. Between the 2023 to 2024 and 2024 to 2025 academic years, MD matriculation declined by 11.6% for Black students (χ21 = 40.59; P < .001) and 10.8% for Hispanic students (χ21 = 45.87; P < .001), respectively. DO programs showed broader underrepresentation. Compared with White and Asian applicants, all other racial groups were significantly underrepresented in both applications and matriculation. These declines threaten progress toward health care equity. Medical schools must explore alternative admissions strategies, such as holistic review processes that account for structural barriers. Without such efforts, reduced diversity in medical education may worsen existing health disparities.
This article describes the federal Medicaid Institutions for Mental Diseases (IMD) exclusion and compares legislative proposals introduced in the 119th Congress-House of Representatives Bill (H.R.) 5662 and H.R. 6727-that seek to repeal this policy. A descriptive policy analysis was conducted using publicly available legislative texts, related federal policy documents, and earlier reviews examining potential impacts of the repeal of the IMD exclusion. The analysis summarizes the statutory basis of the IMD exclusion, reviews existing workarounds, and compares the key mechanisms proposed in H.R. 5662 and H.R. 6727. Potential implications for Medicaid financing and inpatient psychiatric capacity are discussed. The IMD exclusion prohibits federal Medicaid reimbursement for most inpatient psychiatric facilities with more than 16 beds for adults aged 21-64 years, contributing to reliance on state financing and temporary waiver programs. Both H.R. 5662 and H.R. 6727 propose repealing this exclusion. H.R. 5662 would repeal the policy without additional requirements, while H.R. 6727 would also require the U.S. Department of Health and Human Services to establish standards for participating facilities. Repeal would expand eligibility for federal Medicaid funding but would not mandate changes in state utilization or capacity. Recent legislative efforts to repeal the IMD exclusion reflect a growing concern regarding inpatient psychiatric bed shortages and mental health system strain. Understanding the differences between proposed repeal strategies is essential for evaluating how changes in Medicaid financing could affect inpatient psychiatric care and broader behavioral health systems.
Background: In January 2023, British Columbia (BC) implemented a three-year pilot decriminalizing possession of up to 2.5 grams of certain illegal drugs, including opioids, cocaine, methamphetamine, and MDMA, the first policy of its kind in Canada. This initiative has faced scrutiny, culminating in a May 2024 amendment banning possession and use in public spaces.Objectives: To examine public opinion on BC's decriminalization policy by assessing perceptions of the 2024 policy amendment, potential changes in support between 2024 and 2025, and demographic factors associated with support for repealing the policy.Methods: We analyzed two waves of online, non-probability surveys of BC adults (male 48%, non-male 52%): Wave 1 (March 26-April 1, 2024; N = 1,202) and Wave 2 (February 12-18, 2025; N = 1,200). Changes in values between both waves were tested with Rao-Scott chi-square analyses, and demographic predictors of support for the policy's repeal were assessed using multinomial logistic regression.Results: Support for decriminalization weakened between 2024 and 2025, as opposition rose from 41% to 47% (p = .0427). Fewer respondents believed decriminalization reduced criminalization (50% vs. 39%; p < .0001), reduced policing costs (37% vs. 25%; p < .0001), or improved treatment access (34% vs. 27%; p = .0229). Disagreement that decriminalization reduced stigma increased from 45% to 55% (p < .0001), while perceptions of community safety declined from 28% vs. 22% (p = .0019). Overall, 61% supported the amendment, and 46% supported repeal, with support varying by age, gender, region, education, and household composition.Conclusion: Public opinion in BC reflects growing skepticism toward decriminalization, strong support for public use restrictions, and significant backing for the policy's repeal. Without visible improvements in overdose prevention, service access, and public communication, the policy's long-term viability remains uncertain. Sustained investments in harm reduction and strategic public messaging are essential.
Enhanced premium tax credits (PTCs) for Affordable Care Act Marketplace plans expired in 2026. We described families across income groups potentially affected by PTC policy changes and simulated net premiums. We performed a cross-sectional simulation using the 2023 National Survey of Children's Health, classifying families by federal poverty level (FPL) into the following income groups: ineligible (above state Medicaid threshold, <100% FPL), Medicaid (below state threshold), 100-<250% FPL, 250-<400% FPL, and ≥400% FPL. We estimated family premiums using scaled state benchmarks and modeled net premium costs under (1) enhanced PTCs, (2) enhanced PTC expiration, and (3) PTC repeal using ordinary least squares regression adjusting for state fixed effects and family sociodemographics. Families in PTC-relevant income groups had greater material hardship and children with more health conditions but less access than higher-income families. With typical family ages, adjusted net premiums as a percentage of income would be 1.8% (100-<250% FPL), 6.3% (250-<400% FPL), and 8.4% (≥400% FPL) with enhanced PTCs; 6.2%, 9.5%, and 15.2% post-expiration; and 27.1%, 17.8%, and 13.7% with repealed PTCs. In 2023 dollars, net premiums would be $1,335, $6,137, and $9,705 with enhanced PTCs; $4,100, $9,056, and $17,711 post-expiration; and $15,963, $17,069, and $16,903 with no PTCs. Enhanced PTC expiration would increase net premiums substantially, particularly for ≥400% FPL families; full PTC repeal would produce large, regressive premium burdens for lower-income families with children. PTCs should be re-enhanced and not repealed to support American families.
The January 2023 repeal of the X-waiver aimed to reduce regulatory barriers to buprenorphine prescribing and enhance patient access to medications for opioid use disorder (MOUD). Its impact on prescribing by non-addiction-trained physicians, the integration of MOUD training into residency programs, and the role of mandated training on clinical practice remain unclear. A 2024 online survey assessed physicians' awareness of the X-waiver repeal, exposure to MOUD training, and changes in buprenorphine prescribing. Multivariable logistic regression evaluated the independent effect of MOUD training and whether mandatory versus voluntary formats influenced prescribing behavior. Among 959 physicians (42.7 % residents), 88.9 % endorsed the importance of treating patients with MOUD; yet 18.2 % were unaware of the repeal, and 16.8 % reported no MOUD training. Only 25.5 % of non-waivered physicians had initiated prescribing. Residents (28.8 % vs. 20.3 % among attendings; p = 0.02) and physicians in psychiatry (37.2 %), emergency medicine (36.8 %), and family medicine (32.8 %) were more likely to prescribe (p < 0.01). These differences were largely attenuated by MOUD training, which showed the strongest association with prescribing regardless of format. MOUD training, whether mandatory or voluntary, was significantly associated with buprenorphine prescribing. Standardizing training across specialties and institutions may improve buprenorphine uptake.
To evaluate the trends, demographics, and visit characteristics in pediatric emergency department (ED) visits for homelessness in relation to state and federal policies before and during the COVID-19 pandemic. We conducted a retrospective cohort study of pediatric ED visits for homelessness from 2019 to 2021 at an urban tertiary care children's hospital. Visit rates were analyzed in relation to the 2019 repeal of a restrictive shelter eligibility state policy and the implementation and expiration of state and federal COVID-19 eviction moratoria. Demographic and clinical characteristics were compared before and during the pandemic. Among 1045 visits, the rate of pediatric ED visits for homelessness per 1000 total visits declined modestly after the 2019 policy repeal, then spiked in January 2021 following the end of COVID-19 eviction moratoria. During the pandemic, children presenting for homelessness were more likely to be Hispanic (72.5% vs 53.4%; P < .001), have Spanish-speaking caregivers (59.1% vs 40.1%; P < .001), and have chronic medical conditions (25.2% vs 14.6%; P < .001), compared with before the pandemic. Families were less likely to have eviction as the reason for their homelessness (6.2% vs 11.4%; P = .010) during the pandemic and were more likely to cite loss of job or income (11.2% vs 4.9%; P = .001). Pediatric ED visits for homelessness persisted throughout the pandemic, with notable demographic shifts and changing causes of homelessness. These findings demonstrate the inequitable impact of the pandemic on different groups of children, underscore the limitations of temporary housing protections, and highlight the need for durable, equity-driven housing policies.
Sugar-sweetened beverage warning label and excise tax policies hold promise for preventing Type 2 diabetes. Population-level impacts of sugar-sweetened beverage policies have been projected using simulation models, but the authors are unaware of any assessing the effect of warning labels on Type 2 diabetes or the effects of warning label and tax effects using the same modeling assumptions. Simulation models have also rarely considered how policy implementation factors such as design and sustainment affect policy outcomes. Microsimulation model of Type 2 diabetes development in a closed cohort of U.S. adults aged 18-64 years over 10 years with 1,200 replications was performed. The model was developed using the National Health and Nutrition Examination Survey 2017-2018, U.S. Diabetes Surveillance System, and published literature. Policy implementation scenarios were modeled in 2025 for warning label (design: graphic or text warning label) and tax (sustainment: $0.02/fluid ounce excise tax sustained or repealed) policies, compared with the status quo. Relative to the status quo, a graphic warning label was estimated to avert 945,000 cases of Type 2 diabetes over 10 years (95% uncertainty interval=442,000; 1,820,000) compared with 480,000 (95% uncertainty interval=147,000; 1,140,000) cases averted under a text warning label. A $0.02/fluid ounce excise tax was estimated to avert 1,260,000 (95% uncertainty interval=646,000; 2,160,000) cases of Type 2 diabetes over 10 years. If repealed after 1 year, the policy would only avert 78,000 (95% uncertainty interval=0; 469,000) cases of Type 2 diabetes. Sugar-sweetened beverage policies may be an approach to meaningfully decrease the number of individuals with Type 2 diabetes. Policy design and sustainment drive the magnitude of effects.
Safe Patient Handling and Mobility (SPHM) programs address the tasks associated with lifting, moving, transferring, and/or assisting patients in healthcare-related settings. Manual patient handling tasks are a major source of occupational injury among healthcare workers, often resulting in harm to the back and musculoskeletal system. We systematically used legal epidemiology policy surveillance methods to capture and evaluate all state-level SPHM policies for US healthcare settings, recording their scope of coverage and enforceable elements. Since 2006, eleven states have enacted SPHM policies to reduce healthcare worker injuries. Two states repealed them later. These policies tended to target higher acuity settings rather than lower acuity or long-term residential settings and favor administrative controls over engineering controls. Specifically, the most common policy interventions included mandatory training and SPHM committees, while interventions targeting SPHM equipment availability or use were less common. Researchers, labor unions, and policymakers should prioritize engineering controls that impact physical workplace safety when crafting SPHM policy interventions.
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.
Alcohol exclusion provisions (AEPs) in the Uniform Accident and Sickness Policy Provision Law (UPPL) allow insurers to deny claims for alcohol-related injuries. Although many states have repealed AEPs, some enacted explicit prohibitions on intoxication-based claim denials while others did not. This review documents the evolution and current legal landscape of AEPs and evaluates how prior studies have classified these policies. Data were obtained from the Alcohol Policy Information System (APIS) accessed in December 2025 and verified using Westlaw and Nexis Uni. Targeted reviews of the literature on AEPs were conducted. As of 2024, 21 states retain AEPs. Fourteen states and the District of Columbia explicitly prohibit intoxication-based claim denials, 13 states have no UPPL-related provisions, four states limit AEP applicability to disability insurance, and two states maintain policy-specific exceptions. Prior studies frequently overlook these distinctions. Legal heterogeneity remains substantial and may contribute to policy misclassification and biased estimates in empirical evaluations of AEPs. By providing a comprehensive legal mapping of AEP regimes and identifying common methodological shortcomings in the literature, this review offers a framework for improving future research on alcohol-related insurance policies, alcohol screening practices, treatment utilization, and related health outcomes.