There is longstanding debate about the contribution of family planning programs to fertility decline. Studying the staggered introduction of family planning across Malaysia during the 1960s and 1970s, we find modest responses in fertility behavior. Higher (but not lower) parity birth hazards declined by one-quarter—but imply only a 5 percent decline in the overall annual probability of birth. Age at marriage rose by 0.48 years, but birth spacing conditional on this did not otherwise change. Overall, Malaysia’s total fertility rate declined by about one quarter birth under family planning, explaining only about 10 percent of the national fertility decline between 1960 and 1988. Our findings are consistent with growing evidence that global fertility decline is predominantly due to underlying changes in the demand for children.

The recent challenges to the Affordable Care Act (ACA), which has increased the number of individuals with health insurance in the United States but has had little effect on cost, has revived the debate about a single-payer health care system.¹ Whether a single-payer system is the answer or not depends on what question is being asked and what form single payer will take. Single payer can take many forms, and many questions can be asked. This Viewpoint considers 3 problems of US health care: the uninsured, poor health outcomes (relative to other high-income countries), and high cost. In discussing cost, it will be critical to consider the form that a single-payer health care system might take.

The opioid epidemic has claimed more than 300,000 lives in the United States since 20001 and could claim another half million over the next decade. Although heroin and illicitly manufactured fentanyl account for an increasing proportion of opioid-involved overdoses, the majority of persons with opioid addiction started with prescribed painkillers.2 The search for solutions has spread in many directions, and one tentacle is probing the legal accountability of companies that supply opioids to the prescription market. Even as the federal government, among others, pursues civil and criminal actions against physicians and pharmacies to address inappropriate prescribing and dispensing of opioids, a variety of lawsuits have been filed and continue to be filed against opioid manufacturers and distributors.2

Objective: The purpose of this study was to evaluate the impact of objective isolation and loneliness on Medicare spending and outcomes. Method: We linked Health and Retirement Study data to Medicare claims to analyze objective isolation (scaled composite of social contacts and network) and loneliness (positive response to three-item loneliness scale) as predictors of subsequent Medicare spending. In multivariable regression adjusting for health and demographics, we determined marginal differences in Medicare expenditures. Secondary outcomes included spending by setting, and mortality. Results:Objective isolation predicts greater spending, US$1,644 (p < .001) per beneficiary annually, whereas loneliness predicts reduced spending, −US$768 (p < .001). Increased spending concentrated in inpatient and nursing home (skilled nursing facilities [SNFs]) care; despite more health care, objectively isolated beneficiaries had 31% (p < .001) greater risk of death. Loneliness did not predict SNF use or mortality, but predicted slightly less inpatient and outpatient care. Discussion: Objectively isolated seniors have higher Medicare spending, driven by increased hospitalization and institutionalization, and face greater mortality. Policies supporting social connectedness could reap significant savings.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors substantially reduce low-density lipoprotein cholesterol, but it is presently unclear whether they also reduce mortality. The list prices of PCSK9 inhibitors in the United States (>$14,500 per year) are >100× higher than generic statins, and only a small fraction of their higher cost is likely to be recovered by prevention of cardiovascular events. The projected cost effectiveness of PCSK9 inhibitors does not meet generally accepted benchmarks for good value in the United States, but their value would be improved by substantial price reductions. For individual patients, the high out-of-pocket costs of PCSK9 inhibitors may impede access and reduce long-term adherence. The budgetary impact of PCSK9 inhibitors would be very large if all potentially eligible patients were treated, which poses dilemmas for policymakers, payers, and society.