The Senate Committee on Appropriations approved the FY 2024 State, Foreign Operations, and Related Programs (SFOPs) appropriations bill, accompanying report, and amendments on July 20, 2023. The SFOPs bill includes funding for U.S. global health programs at the State Department and the U.S. Agency for International Development (USAID). Funding for these programs, through the Global Health Programs (GHP) account, which represents the bulk of global health assistance, totaled $10.3 billion, a decrease of $239 million (-3%) below the FY 2023 enacted level. All of the decrease is due to reduced funding in the bill for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), though the accompanying report notes that the decline is “a result of the statutory cap on U.S. contributions related to other donor funds” and that “should sufficient matching contributions be available, the Committee intends to honor the $6,000,000,000 U.S. pledge for the seventh replenishment.” Funding for maternal and child health, Gavi the Vaccine Alliance, family planning and reproductive health (FP/RH), and the Health Reserve Fund increased compared to FY 2023 enacted levels; all other global health areas remained flat. See the table below (downloadable version here) for additional detail on FY 2024 Senate levels compared to the FY 2023 Omnibus as well as the FY 2024 President’s Request and FY 2024 House levels. See other budget summaries and the KFF budget tracker for details on historical annual appropriations for global health programs.

In this JAMA Health Forum column, Larry Levitt examines differences in the Republican presidential candidates’ records and positions on health issues, including Medicaid and abortion, that could play a role in the primaries and would set up a sharp contrast in the general election against President Biden.

KFF Health News today launched a new limited-series podcast, “Epidemic: Eradicating Smallpox,” with host Dr. Céline Gounder, senior fellow and editor-at-large for public health at KFF Health News. The eight-episode podcast takes listeners on a journey to South Asia, the site of the last days of variola major smallpox. There, public health workers from India, Bangladesh, and around the world did what many thought was impossible: eradicate smallpox.

“Eradicating smallpox was one of humanity’s greatest triumphs, and it’s one that public health has yet to repeat,” said Dr. Gounder, a physician and epidemiologist. “By telling the stories from the field with the communities and public health workers involved, we can better understand how science, medicine, and the human spirit can dramatically change the course of history.”

In the first episode of the series, listeners will hear how smallpox was seen as both deadly and divine in India through the story of a young boy who overcomes his fear and gets vaccinated after seeing a close friend die of the disease.

In each episode, Dr. Gounder, a public health expert and the KFF Health News medical contributor for CBS News, shares another facet of the historic effort to end smallpox from the field in India and Bangladesh, and also interviews guests who reflect on the strategies and actions of public health workers to help identify relevant lessons for today’s public health emergencies.

New episodes will be available every two weeks on Tuesdays. Listen to the audio trailer here and watch the video trailer on KFF Health News’ YouTube page. 

Firearms were responsible for 20 percent of all child and teen deaths in the U.S. for both 2020 and 2021, compared to an average of less than 2 percent in similarly large and wealthy nations, according to a new KFF analysis. This puts the U.S. far ahead of peer nations in child and teen firearm deaths.

Data show that U.S. firearm deaths for children and teens again surpassed motor vehicle deaths – the second leading cause of death – and that the increase has been primarily driven by gun assault deaths.

On a per capita basis, the firearm mortality rate among children and teens in the U.S. is over 9.5 times the rate of Canada, the country with the second-highest child and teen firearm death rate. If firearm deaths in the U.S. had mirrored Canada’s rates between 2010 and 2021, approximately 30,000 U.S. children and teenagers would still be alive.

Even New York and New Jersey – the states with the lowest child and teen firearm mortality rates among those with available data – have rates that are over three times that of Canada. Among the 38 states with available data, Louisiana, Mississippi, and Alabama had the highest rates of firearm mortality for children and teens ages 1-19 years (17.6, 15.3, and 11.9 deaths per 100,000, respectively).

KFF’s earlier analysis shows that exposure to firearms has important implications for mental health. Among adolescents, gun violence may lead to anxiety, post-traumatic stress disorder, and challenges with school performance, including increased absenteeism and difficulty concentrating

In 2020 and 2021, firearms contributed to the deaths of more children ages 1-17 years in the U.S. than any other type of injury or illness. The child firearm mortality rate has doubled in the U.S. from a recent low of 1.8 deaths per 100,000 in 2013 to 3.7 in 2021.

The United States has by far the highest rate of child and teen firearm mortality among peer nations. In no other similarly large, wealthy country are firearms in the top four causes of death for children and teens, let alone the number one cause. U.S. states with the most gun laws have lower rates of child and teen firearm deaths than states with few gun laws. But, even states with the lowest child and teen firearm deaths have rates much higher than what peer countries experience.

In 2020 and 2021, firearms were involved in the deaths of more children ages 1-17 than any other type of injury or illness, surpassing deaths due to motor vehicles, which had long been the number one factor in child deaths. In 2021, there were 2,571 child deaths due to firearms—a rate of 3.7 deaths per 100,000 children, which is an increase of 68% in the number of deaths since 2000 and 107% since a recent low of 2013.

While the rate of firearm deaths among children has increased since 2000, the rate of motor vehicle deaths is now significantly lower than it had been. The number of motor vehicle deaths among children in 2021 was 49% lower than in 2000, though it did grow during the pandemic by 22% from 2019. Though fewer in number than firearm deaths among children, deaths due to poisonings, which include drug overdoses, have also grown, increasing 186% since 2000 and 103% since 2019.

Provisional CDC data from 2022 indicate that firearms continued to be the number one factor in child deaths for the third year in a row.

Because peer countries’ mortality data are not available for children ages 1-17 years old alone, we group firearm mortality data for teens ages 18 and 19 years old with data for children ages 1-17 years old in all countries for a direct comparison.

On a per capita basis, the firearm death rate among children and teens (ages 1-19) in the U.S. is over 9.5 times the firearm death rate of Canadian children and teens (ages 1-19). Canada is the country with the second-highest child and teen firearm death rate among similarly large and wealthy nations.

As might be expected, teenagers have higher firearm mortality rates than children. In the U.S., teens ages 18 and 19 have a firearm mortality rate of 25.2 per 100,000, compared to a rate of 3.7 per 100,000 for children ages 1-17 in the U.S. Even so, the child firearm mortality rate in the U.S. (3.7 per 100,000 people ages 1-17) is 5.5 times the child and teen mortality rate in Canada (0.6 per 100,000 people ages 1-19).

If the child and teen firearm mortality rate in the U.S. had been brought down to rates seen in Canada, we estimate that approximately 30,000 children’s and teenagers’ lives in the U.S. would have been saved since 2010 (an average of about 2,500 lives per year). This would have reduced the total number of child and teenage deaths from all causes in the U.S. by 13%.

The child and teen (ages 1-19 years) firearm mortality rate varies by state in the U.S. from 2.1 deaths per 100,000 in New York and New Jersey to 17.6 deaths per 100,000 in Louisiana. Even in New York and New Jersey, which have the lowest child and teen firearm mortality rates among those with available data, the rate is still over three times that in Canada.

Because there is no comprehensive national firearm registry, it is difficult to track gun ownership in the U.S. Instead, we look at the correlation between the number of child and teen firearm deaths and the number of gun laws in U.S. states (based on the State Firearm Law Database, which is a catalog of the presence or absence of 134 firearm law provisions across all 50 states).

States with more restrictive firearm laws in the U.S. generally have fewer child and teen firearm deaths than states with fewer firearm law provisions. Even so, these states on average have a much higher rate of child and teen firearm deaths than that of Canada and other countries. Among comparably large and wealthy countries, Canada has the second highest child and teen firearm death rate to the U.S. However, Canada generally has more restrictive firearm laws and regulates access to guns at the federal level. In the U.S., guns may be brought to states with strict laws from out-of-state or unregistered sources.

In 2020 and 2021, firearms were involved in more deaths for children and teens (ages 1-19 years) in the United States than any other type of injury or illness. In 2021, firearms were involved in 4,733 child and teen deaths.

With the exception of Canada, in no other peer country were firearms among the top five causes of childhood and teenage death. Motor vehicle accidents and cancer are the two most common causes of death for this age group in all other comparable countries.

The categories in the chart above are more specific than CDC’s rankable causes of death. We use CDC’s data grouped by injury mechanism and illness. However, given differences in how deaths are grouped by CDC and IHME, we adapt CDC data to be comparable to IHME data. For example, pedestrian deaths are included with motor vehicle and pedestrian deaths in the chart above. See Methods for more details.

Combining all child and teen firearm deaths in the U.S. with those in other OECD countries with above median GDP and GDP per capita, the U.S. accounts for 97% of gun-related child and teen deaths, despite representing 46% of the total population in these countries. Combined, the eleven other similarly large and wealthy countries account for only 153 of the total 4,886 firearm deaths for children and teens ages 1-19 years in these nations, and the U.S. accounts for the remainder.

Firearms account for 20% of all child and teen deaths in the U.S., compared to an average of less than 2% of child and teen deaths in similarly large and wealthy nations.

The U.S. also has the highest rate of each type of child and teen firearm death—suicides, assaults, and unintentional or undetermined intent—among similarly large and wealthy countries.

In 2021 in the U.S., the overall child and teen firearm assault rate was 3.9 per 100,000 children and teens. In the U.S., the overall suicide rate among children and teens was 3.8 per 100,000; and 1.8 per 100,000 child and teen suicide deaths were by firearms. In comparable countries, on average, the overall suicide rate is 2.8 per 100,000 children and teens, and 0.2 per 100,000 children and teens suicide deaths were by firearms.

If the U.S. child and teen suicide by firearm rate was brought down to the same level as in Canada, the peer country with the next highest rate, over 1,000 fewer children and teens would have died in 2021 alone.

The spike in 2020 and 2021 in child and teen firearm deaths in the U.S. was primarily driven by an increase in violent assault deaths. The child and teen firearm assault mortality rate reached a high in 2021 with a rate of 3.9 per 100,000, a 7% increase from the year before and a 50% increase from 2019. The firearm suicide mortality rate among children and teenagers in the U.S. increased 21% from 2019 to 2021.

Exposure and use of firearms also have implications for mental health. Research suggests that youth may experience symptoms of post-traumatic stress disorder and anxiety in response to gun violence. Specifically, survivors of firearm-related injuries, including youth survivors, may be at increased risk of mental health conditions and substance use disorders. Furthermore, gun violence disproportionately affects many children of color, particularly Black children, and children living in areas with a high concentration of poverty.

Since its launch in July 2022, the 988 national suicide and crisis hotline has received about 4 million contacts, a 33 percent increase from the year before, according to a new KFF analysis of publicly available data through May 2023. The contacts include more than 2.6 million calls, over 740,000 chats, and more than 600,000 texts. The total number of contacts rises to almost 5 million when nearly 1 million additional contacts from the Veterans Crisis Line (VCL) are included, which were reported by the federal Substance Abuse and Mental Health Services Administration (SAMHSA), but aren’t yet publicly available.

Overall, the 988 line steers callers who are suicidal or experiencing a behavioral health crisis to the renamed “988 Suicide & Crisis Lifeline,” through which they can be connected to a local Lifeline counselor and may receive crisis counseling, resources, and referrals. Before 988, the Lifeline crisis hotline–established in 2005–was typically accessed through a 10-digit number, which was difficult for callers experiencing a mental health crisis to recall.

Since the 988 launch, there has been a notable increase in the rate of answered contacts, coupled with considerable decreases in waiting times for users. The 988 in-state answer rate varies widely across states, ranging from 55 percent in Alabama to 98 percent in Mississippi in April-May 2023, the latest data available. An in-state answer rate is a measure of the percentage of calls answered within state borders. 988 uses the caller’s area code to route the call to the crisis center closest to that area code.

If local centers don’t answer calls, they are redirected to out-of-state overflow facilities, which handle approximately 8 percent of all calls nationally. If national overflow facility counselors are not familiar with local resources, they may not be able to assist callers with treatment referrals or extra assistance, which can be better provided from local crisis centers.

Although the federal government spent money to assist with the implementation of 988, ongoing funding relies heavily on local and state funds. In May, the Biden administration announced an additional $200 million in funding opportunities to assist states in developing 988 infrastructure and related crisis services.

To date, six states have enacted legislation to fund crisis services through telecom fees, including California, Colorado, Nevada, Virginia, Washington, and most recently Minnesota. Furthermore, Oregon and Delaware are approaching final legislative approval, with new 988 telecom fees having passed in the legislature and awaiting the signature of the governor. Three other states have pending telecommunications fee legislation.

A new report from KFF and The Joint United Nations Programme on HIV/AIDS (UNAIDS) reveals that donor governments disbursed US$8.2 billion in 2022 to combat HIV in low- and middle-income countries, returning to 2020 funding levels and still below the high-water mark of $8.6 billion in 2014. The funding supports HIV care and treatment, prevention, and other services in low- and middle-income countries.

Although total donor government funding for HIV increased in 2022 compared to the year before, this increase was primarily because of the timing of U.S. payments rather than increased donor government commitments.

While there has been significant progress in addressing the HIV epidemic—there were 1.3 million new infections in 2022, down from approximately 2 million a decade ago, and almost half as many AIDS-related deaths—new infections and AIDS-related deaths are on the rise in some regions, including in Eastern Europe and Central Asia and the Middle East and North Africa. Further, more than 9 million people living with HIV still lack access to antiretroviral therapy.

The U.S. continues to be the largest donor to HIV, providing 74% of all donor government HIV funding (US$6.1 billion), followed by France (5%, US$382 million), the United Kingdom (5%, US$376 million), the European Commission (4%, US$328 million), and Germany (2%, US$191 million). The U.S. also ranked first when standardized by the size of its economy, followed by the Netherlands, France, Sweden, and Denmark.

“UNAIDS data show clearly that progress towards ending AIDS is the strongest in the countries that have the most financial investments,” said Winnie Byanyima, Executive Director of UNAIDS. “Today, world leaders are faced with an unprecedented opportunity to end AIDS by 2030. However, globally in 2022, funding was nearly US$ 9 billion short of the US$ 29.3 billion needed by 2025. By investing now, donors will not only push forward the end of AIDS but will also be better prepared for future pandemics.”

“Our analysis shows that donor government funding for HIV is stable but stagnant, with current levels below the high-water mark reached almost a decade ago,” KFF Senior Vice President Jen Kates said. “This contributes to uncertainty ahead, particularly in light of falling domestic resources.”

Donor governments’ bilateral aid—provided directly to or on behalf of specific countries rather than to multilateral organizations—was US$5.6 billion in 2022, an increase of almost US$130 million compared to 2021 (US$5.5 billion), primarily because of the timing of U.S. payments.

Total bilateral funding from donor governments, other than the United States, has decreased each year for more than a decade (by almost US$1.4 billion or 80% since 2011). While increases in multilateral funding have offset these declines in some years, overall funding from these donor governments is still more than US$1.0 billion below where it was just over a decade ago.

The report, “Donor Government Funding for HIV in Low- and Middle-Income Countries in 2022” is part of a collaborative tracking effort between UNAIDS and KFF that began almost 20 years ago, just as new global initiatives were being launched to address the epidemic. The analysis includes data from all 31 members of the Organisation for Economic Co-operation and Development (OECD)’s Development Assistance Committee (DAC), as well as non-DAC members who report data to the DAC.

The data included in this report are also included in a broader UNAIDS global report, which examines all sources of funding for HIV relief, including local governments, non-governmental organizations, and the private sector.

A new KFF analysis finds that the 10 top-selling prescription drugs under Medicare Part D comprised less than 1 percent of all covered drugs in 2021, but accounted for 22 percent, or $48 billion, of gross Medicare Part D drug spending that year.

The analysis provides context for understanding the federal government’s new authority under the Inflation Reduction Act to negotiate prices for some high-spending drugs covered by Part D, Medicare’s outpatient prescription drug benefit program, and Part B, which covers physician and outpatient services, including drugs administered by physicians and other providers.

All of the 10 top-selling Medicare Part D drugs in 2021 were brand-name drugs. Five of them were diabetes drugs, including Ozempic, which belongs to a class of medications that lately have gained attention because they are also effective for weight loss. Other drugs in the top 10 included Eliquis, a blood thinner that was the No. 1 selling drug in 2021, followed by Revlimid, a treatment for multiple myeloma, and Xarelto, a blood thinner.

While the drug price negotiations begin modestly with 10 drugs in the first year, KFF’s research shows that even a relatively small number of drugs can command a substantial share of spending in Medicare. The number of drugs subject to price negotiation will grow in subsequent years and may include drugs covered under Part B beginning in 2028. Drugs will be selected for negotiation from among those with the highest gross prescription drug costs under Medicare.

It is important to note that this analysis, based on 2021 data from the Centers for Medicare and Medicaid Services (CMS), is not designed to identify which drugs are likely to be subject to price negotiation for 2026. CMS will use more current spending data and consider several factors, including FDA approval date and generic availability, in making that determination. CMS will publish the names of the first 10 Part D drugs selected for price negotiation by September 1, 2023.

In 2021, Part D covered more than 3,500 prescription drug products, with total gross spending of $216 billion, not accounting for rebates paid by drug manufacturers to pharmacy benefit managers. Total Part B drug spending was $40 billion on more than 600 covered drugs in 2021, but Part B drugs will not be subject to price negotiation until 2028.

The Inflation Reduction Act requires the federal government to negotiate the price of certain high-spending drugs covered by Medicare Part D, Medicare’s outpatient prescription drug benefit program, and Medicare Part B, which covers physician and outpatient services, including drugs administered by physicians and other providers. Under the new Medicare Drug Price Negotiation Program, the number of drugs subject to price negotiation will be limited to 10 Part D drugs for 2026, another 15 Part D drugs for 2027, another 15 Part D and Part B drugs for 2028, and another 20 Part D and Part B drugs for 2029 and later years. The number of drugs with negotiated prices available will accumulate over time.

The 10 Part D drugs that will be selected for price negotiation for 2026 will be published by September 1, 2023. These 10 drugs will be chosen from the top 50 negotiation-eligible Part D drugs with the highest total Medicare Part D expenditures (defined as total gross covered prescription drug costs). Subject to specific exclusions and exceptions, drugs qualify for price negotiation if they are single-source brand-name drugs or biological products without therapeutically-equivalent generic or biosimilar alternatives, and are at least 7 years (for small-molecule drugs) or 11 years (for biologics) past their FDA approval or licensure date, as of the date that the list of drugs selected for negotiation is published.

This analysis provides context for understanding the potential impact of negotiating prices for a limited number of Medicare-covered drugs by identifying the 10 top-selling drugs in 2021, measuring the share of total Medicare Part D drug spending accounted for by top-selling drugs that year, and examining changes in spending and use of these drugs since 2018 (the first year that all 10 of the drugs were covered under Part D). We focus on drugs covered under Part D, rather than Part B, since negotiation will be limited to Part D drugs for the first two years of the negotiation program. We ranked drugs by total gross spending in 2021 since that is the measure that will be used to rank drug products in the negotiation program. Our analysis is based on Centers for Medicare & Medicaid Services’ data on Medicare Part D spending by drug.

It is important to note that this analysis is not designed to identify which drugs are likely to be subject to price negotiation for 2026, since we do not take into account all of the factors that determine whether a drug is negotiation-eligible and we do not have access to the more current spending data that CMS will use in selecting drugs for price negotiation.

A small number of drugs account for a disproportionate share of Medicare Part D prescription drug spending, with the 10 top-selling drugs accounting for nearly one-fourth of gross Part D spending in 2021

In 2021, Medicare Part D covered more than 3,500 prescription drug products, with total gross spending of $216 billion, not accounting for rebates paid by drug manufacturers to pharmacy benefit managers (PBMs). The 10 top-selling Part D drugs accounted for 0.3% of covered drugs and 22% of total gross Medicare drug spending in 2021 (Figure 1). The top 100 drugs, representing just 3% of covered drugs, accounted for 61% of total gross spending that year.

Total gross spending on the top 10 Medicare Part D drugs in 2021 ranged from $2.6 billion for Ozempic, a diabetes drug, to $12.6 billion for Eliquis, a blood thinner

In the aggregate, gross Medicare drug spending on the top 10 Part D drugs in 2021 was $48 billion. Eliquis, a blood thinner manufactured by Bristol Myers Squibb, was the top-selling drug, accounting for a quarter of this total, or $12.6 billion (Figure 2). Gross Medicare Part D spending exceeded $5 billion for both Revlimid, a treatment for multiple myeloma also manufactured by Bristol Myers Squibb, and Xarelto, a blood thinner manufactured by Janssen.

Five of the 10 top-selling Part D drugs in 2021 are diabetes drugs: Trulicity, Januvia, Jardiance, Lantus Solostar, and Ozempic. Notably, Ozempic belongs to a class of medications that have gained attention in recent months because they are highly effective weight loss agents. Manufactured by Novo Nordisk, Ozempic was approved by the FDA in 2017 as a treatment for type 2 diabetes. While Medicare does not cover Ozempic when prescribed off-label for weight loss due to the current law prohibition on Medicare coverage of drugs when used for weight loss, it is covered as a diabetes drug. Gross Part D spending on Ozempic, used by 0.5 million Part D enrollees in 2021, totaled $2.6 billion.

Also included in the top 10 is Imbruvica, a cancer treatment manufactured by Pharmacyclics, with gross Medicare spending of $3.2 billion in 2021, and Humira Citrate-free (Cf) pen, a treatment for rheumatoid arthritis (among other conditions), manufactured by Abbvie, with gross Medicare spending of $2.9 billion in 2021. (While the original version of Humira was approved in 2002, Abbvie launched the citrate-free version in 2018). Gross Medicare spending across all formulations of Humira totaled $4.7 billion in 2021, including the citrate-free and original versions and various formulations and dosages of each version approved for different indications and populations.

In the aggregate, gross Medicare spending for the 10 top selling Part D drugs more than doubled between 2018 and 2021

Between 2018 and 2021, aggregate gross spending on the 10 top-selling drugs in 2021 increased from $22 billion to nearly $48 billion. The increase in gross spending on these 10 drugs alone accounted for more than half of the increase in gross Medicare spending across all covered Part D drugs over these years. In the aggregate, gross Part D spending rose from $166 billion in 2018 to $216 billion in 2021.

Over these years, total gross Part D spending on Eliquis, the top selling drug in Medicare Part D in 2021, increased by 2.5 times from $5 billion in 2018 to $12.6 billion in 2021; gross spending for the diabetes drug Trulicity more than tripled from $1.4 billion to $4.7 billion; and gross spending on the diabetes drug Jardiance increased more than five times from $0.7 billion to $3.7 billion (Figure 3). For all of these drugs, the percentage increase in gross spending between 2018 and 2021 outpaced the percentage increase in the number of users over these years (data not shown, see Figure 2 for number of users per drug in 2018 and 2021).

Conclusion

The Medicare drug price negotiation program established by the Inflation Reduction Act is designed to target high-spending drugs that have been on the market for several years and lack generic or biosimilar competition. CBO estimates nearly $100 billion in Medicare savings between 2026 and 2031 from the drug negotiation program. Our analysis shows that Medicare Part D spending is highly concentrated among a small share of covered brand-name drugs, and that increases in gross spending on the 10 top-selling drugs have contributed to a substantial increase in overall Medicare drug spending in recent years.

While this analysis is not designed to identify which drugs will be selected for negotiation for 2026, two of the 10 top-selling Part D drugs in 2021 would not be eligible for selection based on when they were approved (Trulicity, a biologic approved in 2014, and Ozempic, a small-molecule drug approved in 2017) and three would not be eligible for selection based on generic or biosimilar availability in 2023 (Revlimid, Humira, and Lantus). The final list will be determined based on more current spending data than is publicly available and consideration of several factors not included here. While all of the 10 top-selling Part D drugs in 2021 will not be included on the list of 10 drugs selected for price negotiation this year, this analysis suggests that targeting negotiation on a small number of high-spending drugs could affect a disproportionate share of Medicare drug spending in the future.