US Hospital Service Availability and New 340B Program Participation.

Importance: The US 340B Drug Pricing Program enables eligible hospitals to receive substantial discounts on outpatient drugs to improve hospitals' financial sustainability and maintain access to care for patients who have low income and/or are uninsured. However, it is unclear whether hospitals use program savings to subsidize access as intended. Objective: To evaluate whether the 340B program is associated with improvements in access to hospital-based services and to test whether the association varies by hospital ownership. Design, Setting, and Participants: Difference-in-differences and cohort analysis from 2010 to 2019. Never and newly participating 340B general, acute, nonfederal hospitals in the US using data from the American Hospital Association's Annual Survey of Hospitals merged with hospital and market characteristics. Data were analyzed from January 1, 2023, to January 31, 2024. Exposures: New enrollment in 340B between 2012 and 2018. Main Outcomes and Measures: Total number of unprofitable service lines, ie, substance use, psychiatric (inpatient and outpatient), burn clinic, and obstetrics services; and profitable services, ie, cardiac surgery and orthopedic, oncologic, neurologic, and neonatal intensive services. Results: The study sample comprised a total of 2152 hospitals, 1074 newly participating and 1078 not participating in the 340B program. Participating hospitals were more likely than nonparticipating hospitals to be critical access and teaching hospitals, have higher Medicaid shares, and be located in rural areas and in Medicaid expansion states. At public hospitals, participation in the 340B program was associated with a significant increase in total unprofitable services (0.21; 95% CI, 0.04 to 0.38; P = .02) and marginal increases in substance use (5.4 percentage points [pp]; 95% CI, -0.8 pp to 11.6 pp; P = .09) and inpatient psychiatric (6.5 pp; 95% CI, -0.7 pp to 13.7 pp; P = .09) services. Among nonprofit hospitals, there was no significant association between 340B and service offerings (profitable and unprofitable) except for an increase in oncologic services (2.5 pp; 95% CI, 0.0 pp to 5.0 pp; P = .05). Conclusions and Relevance: The finding of the cohort study indicate that participation in the 340B program was associated with an increase in unprofitable services among newly participating public hospitals. Nonprofit hospitals were largely unaffected. These findings suggest that public hospitals responded to 340B savings by improving patient access, whereas nonprofits did not. This heterogeneous response should be considered when evaluating the eligibility criteria for the 340B program and how it affects social welfare.

Creating smoke-free places through the UN Convention on the Rights of Persons With Disabilities.

In some high-, middle-, and low-income countries, law has been employed to limit individuals' secondhand smoke exposure. Innovative legal tools are still needed, especially in low- and middle-income countries where smoking prevalence continues to rise. For some persons with severe respiratory conditions, the presence of secondhand smoke is intolerable and prevents their entrance into restaurants and other venues. With its adoption of the Convention on the Rights of Persons with Disabilities (CRPD) in 2006, the United Nations gave countries a new way to promote the rights of disabled individuals and simultaneously address secondhand smoke exposure. We analyze the CRPD's potential to advance tobacco control goals and offer recommendations for advocates, policymakers, and others seeking to apply this approach.

Competing initiatives: a new tobacco industry strategy to oppose statewide clean indoor air ballot measures.

To describe how the tobacco and gaming industries opposed clean indoor air voter initiatives in 2006, we analyzed media records and government and other publicly available documents and conducted interviews with knowledgeable individuals. In an attempt to avoid strict "smoke free" regulations pursued by health groups via voter initiatives in Arizona, Ohio, and Nevada, in 2006, the tobacco and gaming industries sponsored competing voter initiatives for alternative laws. Health groups succeeded in defeating the pro-tobacco competing initiatives because they were able to dispel confusion and create a head-to-head competition by associating each campaign with its respective backer and instructing voters to vote "no" on the pro-tobacco initiative in addition to voting "yes" on the health group initiative.