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Background: State policy-making to address disparities in access to and quality of palliative care is increasing. Yet, there is no mechanism to systematically assess palliative care policies nationally. Methods: We describe the development of the Palliative Care Law and Policy GPS by the Center to Advance Palliative Care and the Yale Solomon Center for Health Law and Policy. The GPS is an online, searchable repository of national palliative care policies. We developed the GPS by conducting a systematic search of Lexis+, LegiScan, and state health departments for palliative care-related statutes and proposed legislation, categorizing policies into workforce, payment, quality/standards, clinical skill-building, public awareness, telehealth, and pediatric palliative care, and creating an interactive website. Conclusions and Implications: The GPS is a critical tool that can advance palliative care research, practice, and policy. Next steps include the expansion of data from 2010 onward as well as gathering state-level regulations and partially automating search and updating functions. [ABSTRACT FROM AUTHOR]

Federa Uudges resolved more than eighty-seven percent Of appeals through unpublished opinions ouer the past five years. 7hese dispositions are non-precedential and typically contain abbreviated reasoning. Such high rates of nonpublica tion may be difficult to reconcile with the core values of the federal judiciary-values grounded in precedent, reason-giving, and equal treatment. Atter intense attention to the prevalence of unpublished opinions some Been years ago, far less attention has been paid to the phenomenon in recent years. But a new debate is beginning to emerge. This Article makes three contributions to the ongoing conversation. First, it brings hard data to the debate. Drawing on a dataset Of over 400,000 appeals *om the Federal Judicial Center and a sample of more than 1,400 unpublished opinions randomly selected Ji-om six-federal circuits, this Article examines nonpublication rates across several dimensions, inctuding case type, party type, and outcomes. For example, from 2008 to 2018, pro se, or as we will refer to them, self-represented, appellants were twelve times less Wcely to receive a published opinion than appellants represented by counsel. Appeals initiated by incarcerated people and immigrants also had publication rates signvicantly below the baseline for all appeals. In contrast, when the United States is the underlying plaint(ff, opinions are published at a signiticantly higher-thanusual rate. These findings reveal a pattern Of dtfferential treatment that merits attention. Second, we introduce an expanded theoretical*amework for evaluating unpublished opinions. Rather thanfocusing on a single feature of these opinions (e.g., their nonprecedential status) we utilize a framework that highlights the dynamic tradeoffs involved in any system of publication and reveals that precedent, reason-giving, citation, and public dissemination- the primary features of judicial opinions implicated by nonpublication-combine to q#ect the legal system's core ualues in complex, context-dependent, and sometimes Ofsetting ways. Finally, an important takeaway from our piece relates to the serious transparency problems that peruade current nonpublication practices. Our work uncovered significant barriers to accessing and studying unpublished opinions on a large scale. These barriers make it difficult for scholars, the public, and even some judges to find these opinions, much less to study them and understand the effects Of nonpublication on the judicial system and those who participate in it. [ABSTRACT FROM AUTHOR]

Over the past 50 years, multidistrict litigation (MDL) has quietly revolutionized civil procedure. MDLs include the largest tort cases in U.S. history, but without the authority of the class-action rule, MDL judges--who formally have only pretrial jurisdiction over individual cases--have resorted to extraordinary procedural exceptionalism to settle cases on a national scale. Substantive state laws, personal jurisdiction, transparency, impartiality, reviewability, federalism, and adequate representation must all yield if doing so fulfills that one goal. Somehow, until now, this has remained below the surface to everyone but MDL insiders. Thanks to the sprawling MDL over the opioid crisis--and unprecedented opposition to it--MDL is finally in public view. State attorneys general have resisted the opioid MDL's intense nationalism, its relentless drive to global settlement, its wild procedural innovation, its blurring of differences across state law, and its dramatic assertions of jurisdictional authority. Opiates is the most extraordinary MDL yet, but most big MDLs share many of its features, and Opiates is already the roadmap for the next mega-cases. Moreover, even as resistance to Opiates has dispersed some of the MDL's early power, that resistance itself has come in the form of unusual procedural mechanisms. MDL is designed for individual cases--giving similar suits filed in different districts an efficient pretrial process before sending them home for trial. In reality, that is pure fiction. Few cases ever return. And the MDL's mode of coordination--from its anti-federalism stance to its insistence that each proceeding is too unique to be confined by the Federal Rules--chafes at almost every aspect of procedure's traditional rules and values. MDL is not-so-secretly changing the face of civil procedure. This Article weaves together for the first time these exceptional features of MDL and their disruption of procedure's core assumptions. Is MDL a revolution? Or simply a symptom of a larger set of modern procedural tensions manifesting in many forms? Either way, it begs the question: What do we expect of litigation on this scale? We recognize that MDL fills important gaps by providing access to courts but argue for some return to regular order to safeguard due process, federalism, and sovereignty. We suggest specific shifts--from more pretrial motions to new paths for appellate review, attorney selection, and jurisdictional redundancy--where the normative balance seems particularly out of whack; shifts we believe are in line with the spirit of Federal Rule 1's own inherent paradox--the ideal of "just, speedy and inexpensive procedure.". We also offer the first comprehensive analysis of the historic suits over the opioid crisis. Opiates is the first MDL that pits localities against their own state attorneys general in a struggle for litigation control. Its judge has publicly stated that solving a national health crisis that Congress dumped in his lap is different from ordinary litigation. Opiates has even invented a new form of class action. It is hyperdialectical, jurisdictionally competitive, outcome-oriented, repeat-player-rich, fiercely creative procedure. [ABSTRACT FROM AUTHOR]

Firearm injury in the United States is a public health crisis in which physicians are uniquely situated to intervene. However, their ability to mitigate harm is limited by a complex array of laws and regulations that shape their role in firearm injury prevention. This piece uses four clinical scenarios to illustrate how these laws and regulations impact physician practice, including patient counseling, injury reporting, and the use of court orders and involuntary holds. Unintended consequences on clinical practice of laws intended to reduce firearm injury are also discussed. Lessons drawn from these cases suggest that physicians require more nuanced education on this topic, and that policymakers should consult front-line healthcare providers when designing firearm policies. [ABSTRACT FROM AUTHOR]

The article focuses on congressional bureaucracy is the collection of approximately a dozen nonpartisan offices largely ignored by courts and practicing lawyers. It mentions Congress's own internal separation of powers and safeguards the legislative process from executive and encroachment. It also mentions several Congress's nonpartisan legislative institutions which include Congressional Research Service (CRS); Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT).

The article discusses the Affordable Care Act (ACA), its benefits, as well as its resiliency amidst the challenges it confronted like court litigations, congressional repeal bills, and administrative strangulation in federal and various states in the U.S.

The next steps in health reform, like all such efforts before it, will have to engage the issue of American health care federalism – the relationship between the federal and state governments in the realm of health law and policy. Since its enactment in 2010, the Patient Protection andAffordable Care Act (ACA) has offered a robust example of modern federalism and revealed new complexities. This article recounts the findings of our five-year study of the federalist and nationalist features of ACA implementation. Contrary to the claims of ACA opponents that the law marked a federal "takeover," the ACA's governance structures have advanced rather than suppressed state power. But we also found that the advances in state power occurred seemingly independently of the statute's structural arrangements; that is, the ACA's nationalist and federalist features both enhanced state power over health policy. These findings raise questions about whether cherished American federalism values are unique to federalist structures; they also raise the question of what exactly health care federalism is for, and why we continue to design health policy with federalism front and center. It is not clear that enhanced state power has brought better health policy. If it has not, is federalism for its own sake worth the trade-off? [ABSTRACT FROM AUTHOR]

The article discusses the role of courts and civil litigation during the U.S. opioid crisis of the early 21st century. It examines legal claims against the pharmaceutical industry such as Purdue Pharma and retail pharmacies that have evolved into multidistrict litigation (MDL), and comparisons between opioid abuse and tobacco lawsuits that resulted in the Master Settlement Agreement of 1998.

The article discusses the role of specialty and primary care physicians in pain and drug addition management in the context of the opioid crisis in the U.S. during the early 21st century. It touches on the legislation the Drug Addiction Treatment Act of 2000, the attitude of the pharmaceutical industry, and government regulation concerning prescription drugs.

Multidistrict litigation (MDL) is unorthodox, modern civil procedure. It is an old-but-new procedural tool that significantly disrupts decades of worked-out doctrinal equilibria--and, now comprising a shocking 39% of the cases on the civil docket, MDLs warrant more attention than they have received. The MDL puts a thumb on the scale of nationalism over federalism, consent over adversity, procedural exceptionalism over transsubstantivity, and common law over the Federal Rules. In other words, the MDL takes what has generally been the losing side of procedure's big theoretical and doctrinal debates; it is a symptom of deeper pressures on the system to recalibrate procedure's traditional baselines. MDLs are modern because they see the need for a national, not state-centered, approach to questions of procedure. They disrupt traditional legal relationships, turning judges and lawyers into collaborative partners in practical problem solving and creating a new judicial elite among the federal judges chosen to lead them. MDLs exemplify procedural exceptionalism--a type of litigation that judges insist is too different from case to case to be managed by the transsubstantive values that form the very soul of the Federal Rules. Instead, judges develop their own special MDL procedures--yet this new kind of procedural law is rarely treated as precedential or even subject to customary appellate review. These deviations from the "textbook" have caused academic anxiety. Scholars worry about lack of transparency, loss of the individual claim, and the dearth of uniform procedural law. Many judges who try MDLs, on the other hand, view them favorably--often as the only way to ensure access to court for massive claims on a national scale--and also as highly enjoyable judicial work. This Article relies on interviews with MDL judges to offer a new set of counterpoints to the academic criticism. The Article also sets MDLs in the broader context of "unorthodox lawmaking"--a phenomenon documented in the legislative context but not yet in procedure. MDLs, like omnibus legislation and other forms of nontraditional lawmaking, are responses to pressure on the system, some way in which legal rules have not kept up with the obstacles of modern times when the consensus is that Congress and the courts must nevertheless take action. All of these unorthodox vehicles thus tend to operate outside the relevant rules, raising questions about the value of the rules themselves. They raise the question: What do we care about most? Is it access to court (or, analagously, the production of legislation)? Or is procedure for procedure's own sake the more important value--even if upholding that value means fewer cases get resolved? MDLs highlight this tension. They are likely more symptom than cause of procedure's modern challenges. [ABSTRACT FROM AUTHOR]

The formalist project in statutory interpretation, as it has defined itself, has been a failure. That project--typified by but not limited to Justice Antonin Scalia's brand of textualism--has been doomed because even its staunchest supporters have been unwilling to carry it out. The rules that judges employ are too numerous to be predictably chosen. There is no ranking among them. They are not treated as blackletter, precedential law. Even formalist-textualist judges, it turns out, crave interpretive flexibility, do not want to be controlled by other courts or Congress, and feel the need to show their interpretive actions are democratically linked to Congress. What we actually have instead is an approach whose legitimacy depends, in large part, on understanding how Congress works. Establishing the incomplete execution of formalism is a crucial first step in this argument, because the fiction that textualism has been successful in achieving its goals has prevented us from seeing what judges actually want and, in fact, are actually doing. With that understanding, it becomes clear that better judicial understanding of the realities of congressional drafting practice will not only make statutory interpretation practice more legitimate, but also advance the enterprise of what most judges--even formalists--already see their job to be. If formalism originally began as a second-best alternative to understanding Congress, understanding Congress has emerged as a second-best alternative to carrying out the formalist project. After laying this groundwork, this Essay offers ten new rules of statutory interpretation--objective, formalism-compatible rules, but rules grounded in congressional practice. It especially highlights one new rule--the CBO Canon--and then offers nine more, including an anticonsistency presumption and presumptions about different legislative vehicles, multiple agency delegations, dictionaries, and special legislative history. Judges of all interpretive stripes have shown new interest in applying this kind of real-world understanding of the legislative process to statutory interpretation doctrine. The goals here are to explore why that might be the case; to meet some of the objections that have been raised about the use of such evidence; and to offer examples to illustrate the very possibility of what might be, and in some cases already is. [ABSTRACT FROM AUTHOR]

The article discusses health law in the age of the modern regulatory state and also focuses on why health lawyers must be public law lawyers. It reveals how the 2010 health reform Affordable Care Act (ACA) illustrates the need of understanding public-law domain including the U.S. Congress and federal agencies in shaping health law in the U.S. It also mentions that the health law has come from the states, local governments, and the medical profession.

Chevron, the most famous rule of administrative law, is also a central doctrine of statutory interpretation. But Chevron is understood and operates quite differently from most of the other statutory interpretation rules. This Essay explores six such divergences and how they illuminate of some the most important, unanswered questions of the statutory era. First, thirty years of Chevron highlight the enduring puzzle over the legal status of statutory interpretation methodology in general. Chevron is a "precedent;" the remaining statutory interpretation doctrines do not even rise to the status of "law." But second, Chevron's own fate is inextricably tied to these other rules, because Chevron relies on them in its famous two-step test. Critics blame Chevron's manipulability, but arguably the blame lies more with the legal indeterminacy of all of the other statutory interpretation rules upon which Chevron relies. Third, as the Chevron doctrine has evolved, it has become more attendant to the realities of how Congress drafts statutes--realities in which the Court seems wholly uninterested when it comes to the rest of statutory interpretation. Relatedly, the Court shows no shame in acknowledging Chevron's source; the Court created the doctrine. The jurisprudential status of the other interpretive rules, however, remains ambiguous, with the federal courts loathe to admit that they have fashioned a common law of statutory interpretation. Fourth, Chevron, as further developed by Mead, is the one instance in which the Court has explicitly used interpretive doctrine to influence the procedures that Congress uses. Again in contrast, across the rest of the statutory landscape, the Court has refused to enter the sausage factory, continuing to reject the idea that courts should interfere in the lawmaking process, or that how a law is made should affect its interpretation. Fifth, Chevron's evolution has blown a hole through conventional notions of statutory stare decisis, but at the same time the Court now seems afraid that it has given away too much. Today, agency statutory interpretations may displace judicial precedents but, when agencies are not in the picture, the Court hoards power: it gives its own statutory precedents "super" stare decisis effect; is stingy when it comes to interpreting congressional overrides; and won't cede any control over interpretive rules to any other branch. Finally--and this is a shared feature--both Chevron and the rest of the statutory interpretation rules rest on an outmoded, "Schoolhouse Rock!" understanding of Congress and agencies that is no more, if it ever was. Thirty years of Chevron thus reveal a statutory law--landscape in remarkable flux, and a Court making few connections between the closely linked administrative and statutory domains. [ABSTRACT FROM AUTHOR]

"National Federalism" best describes the modern allocation of state and federal power, but it is a federalism without doctrine. Federalism today comes primarily from Congress- through its decisions to give states prominent roles in federal schemes and so to ensure the states' continuing relevance in the statutory era. As a result, many of the most significant state sovereign acts now occur through state implementation of federal statutory law, but we have no law to effectuate this account of state authority. This is National Federalism: nationalism and federalism, simultaneous and in tension-and generated entirely by federal statutes. Unlike traditional federalism, it is neither a constant presence nor an entitlement: rather, it is a feature of federal statutory design. But nor does it have the usual trappings of nationalism, because it incorporates experimentation, variety and state historical expertise-the classic "federalism" values-into national law. State sovereignty remains, even if law does not yet recognize it as such. States pass state legislation, appoint new state officials and hear state-law cases in state courts, all as part of their work to implement federal statutory law, but in many ways autonomous from it. Yet, instead of having Chevron-like doctrines that give implementing states more policymaking discretion; or jurisdictional rules that keep more of these cases in state courts; or choice-of-law regimes requiring that state standards of review and state rules of administrative procedure should apply to the state laws enacted by states legislatures that shape the local implementation of federal law in ways unique to each state-instead of all of that, we have a doctrinal muddle and a Court that does not even see these questions as federalism questions in the first place. This essay develops the account of Congress as our primary source of federalism, and re-situates nationalism within that account. It then assembles a list of fifteen unresolved doctrinal questions that reveal the complexity and importance of federalism's modern statutory domain. [ABSTRACT FROM AUTHOR]

This is the second of two Articles relaying the results of the most extensive survey to date of 137 congressional drafters about the doctrines of statutory interpretation and administrative delegation. The first Article focused on our respondents' knowledge and use of the interpretive principles that courts apply. This second Article moves away from the judicial perspective. Our findings here highlight the overlooked legislative underbelly: the personnel, structural, and process-related factors that, our respondents repeatedly volunteered, drive the details of the drafting process more than judicial rules of interpretation. These factors range from the fragmentation caused by the committee system, to the centrality of nonpartisan professional staff in the drafting of statutory text, to the use of increasingly unorthodox legislative procedures--each of which, our respondents told us, affects statutory consistency and use of legislative history in different and important ways. Our respondents also painted a picture of legislative staffers in a primary interpretive conversation with agencies, not with courts, and as using different kinds of signals for their communications with agencies than courts consider. Most of the structural, personnel, and process-related influences that our respondents emphasized have not been recognized by courts or scholars, but understanding them calls into question almost every presumption of statutory interpretation in current deployment. The findings undermine the claims of both textualists and purposivists that their theories are most democracy enhancing, because neither makes satisfactory efforts to really reflect congressional expectations. Our findings challenge textualism's operating assumption that text is always the best evidence of the legislative bargain and suggest more relevant--but still formalist--structural features that might do better. Our findings further reveal that, although purposivists or eclectic theorists may have the right idea with a more contextual approach, many of the factors on which they focus are not the same ones that Congress utilizes. With respect to delegation, our findings suggest that, for both types of theorists, Chevron now seems too text- and court-centric to actually capture congressional intent to delegate, although that has been its asserted purpose. In the end, our findings raise the question whether the kind of "faithful agent" approach to interpretation that most judges currently employ--one aimed at effectuating legislative deals and often focused on granular textual details--can ever be successful. We thus look to different paradigms less dependent on how Congress works, including rule-of-law and pragmatic approaches to interpretation. These alternatives respond to the problem of the sausage factory, but pose different challenges in light of the modern judicial sensibility's pronounced concern with legislative supremacy. [ABSTRACT FROM AUTHOR]

The author comments on the decision of a U.S. federal judge on the case, Halbig v. Sebelius, on January 15, 2014, wherein a challenge to the new health insurance exchanges created under the Affordable Care Act (ACA) was rejected, and its benefit to health insurance exchanges. The author discusses the effect on ACA if the challenge succeeded, the appeal of the ruling and the subsidies being provided by the ACA to individuals purchasing insurance on these exchanges.

The article discusses the United States \40,000 people die annually as a result of being shot by a firearm. Topics include the articles put medical practice in dialogue with legal doctrine; sociological approaches in dialogue with criminal justice; and the papers loosely fall to four categories, all have in conversation, criminal justice, medicine and public health.

What role should the realities of the legislative drafting process play in the theories and doctrines of statutory interpretation and administrative law? The ongoing debates frequently turn on empirical assumptions about how Congress drafts and what interpretive rules Congress knows, but, until now, there has been almost no testing of those assumptions. This is the first of two Articles reporting the results of the most extensive empirical study to date--a survey of 137 congressional staffers drawn from both parties, both chambers of Congress, and spanning multiple committees--on topics ranging from their knowledge and use of the canons of interpretation, to legislative history, the administrative law deference doctrines, the legislative process, and the courts-Congress relationship. Our findings have implications for virtually every swath of the interpretive debates. We can report, for instance, that there are some canons that our drafters know and use--Chevron and the presumption against preemption, for example; but that there are other canons that many drafters know but consciously reject in favor of political or other considerations, including the presumption in favor of consistent usage, the rule against superfluities, and dictionary use; and that there are still other canons, like Mead and noscitur a sociis, that our drafters do not know as legal rules but that seem to be accurate judicial reflections of how Congress drafts. Our interviews also elicited a treasure trove of information about key influences on the drafting process that legal doctrine rarely acknowledges. These findings also allow us to press for a more precise answer to a foundational question: what should be the purpose of these rules? Judges, often using the unhelpful generalization that they are Congress's "faithful agents," have legitimized them using conflicting justifications, some of which turn on empirical reality, some of which do not, and most of which treat together many different types of rules that do very different types of work. Do the canons reflect how Congress drafts, and so effectuate legislative supremacy? Or do judges use the canons for more dialogical reasons, such as to encourage Congress to draft more precisely--and does Congress listen? Might the canons instead best be understood to effectuate judicial responsibilities that are external to the legislative process, such as advancing constitutional values or legal coherence? Our study disaggregates the canons, revealing the variety of justifications for the current regime and how each rests on different visions of the judicial power and the courts-Congress relationship. [ABSTRACT FROM AUTHOR]

State implementation of federal law is commonplace, but has been largely ignored by the interpretive doctrines of legislation and administrative law. We have no Chevron, federalism canon, or anything else for state implementation, nor any doctrines that ask how Congress's decisions to delegate implementation duties to states should affect how ambiguous statutes should be interpreted. For theories of federalism, state implementation raises a different question, namely, whether this "intrastatutory federalism"—an informal federalism that comes from the inside of federal statutes—is something that doctrine should protect. The prevailing functional and sovereignty accounts of federalism seem less relevant for a federalism that comes at the grace of Congress; this federalism belongs to the domain of statutory interpretation. This Essay argues that state implementation of federal law plays many different roles, and that those differences should affect both how statutes are interpreted and how they are conceived from a federalism perspective. Sometimes state implementation effectuates traditional federalism values like experimentation, but at other times it seems to serve more nationalizing functions, like statutory entrenchment and even federal law encroachment. This variety poses challenges for legislation doctrine, because the prevailing canons of interpretation are not designed to capture such differences, and it illustrates that the broad category of cooperative federalism is more nuanced than commonly acknowledged. [ABSTRACT FROM AUTHOR]

Do the Erie Doctrine and its "reverse-Erie" mirror require state and federal courts to apply one another's statutory interpretation methodologies when they interpret one another's statutes? Surprisingly, the courts have no consistent answer to this question - even though state and federal courts constantly interpret one another's laws. What's more, exploring this application of Erie reveals that one of the most important jurisprudential questions about statutory interpretation also remains entirely unresolved: namely, are the rules of statutory interpretation "law," individual judicial philosophy, or something in between? This Article argues that many federal courts are getting the Erie question wrong- or at least that they are unaware that the question exists in the first place. The Erie inquiry also makes clear that federal courts treat both state and federal statutory interpretation methodology as much less "lawlike" than they treat analogous interpretive principles, without acknowledging or justifying the distinction. Federal courts routinely bypass state interpretive principles when they interpret state statutes, but almost always look to other state methodological principles, including state rules of contract interpretation, choice of law, and constitutional interpretation. Further, unlike in those other areas, the U.S. Supreme Court does not treat even its own statements about federal statutory interpretation principles as "law" and does not give them precedential effect. This practice has licensed an interpretive freedom for state and lower federal courts when those courts interpret federal statutes - a freedom that facilitates federal-law disuniformity that the Court generally does not tolerate in other contexts. This Article challenges the notion that statutory interpretation is sufficiently different from other decisionmaking regimes to justify these distinctions. [ABSTRACT FROM AUTHOR]

This Article offers the first close study of statutory interpretation in several state courts of last resort. While academics have spent the past decade speculating about the "death of textualism," the utility of legislated rules of interpretation, and the capacity of judges to agree on a single set of interpretive rules, state courts, as it turns out, have been engaging in real-world experiments in precisely these areas. Several state courts have articulated governing interpretive regimes for all statutory questions. Methodological stare decisis - the practice of giving precedential effect to judicial statements about methodology - is generally absent from federal statutory interpretation, but appears to be a common feature of some states' statutory case law. Every state legislature in the nation has enacted certain rules of interpretation, which some state courts are, in an unexpected twist, flouting. And, far from textualism being "dead," what emerges from these state cases is a surprisingly strong consensus methodology--what this Article terms "modified textualism" -- a theory that shares textualism's core components but has broader potential appeal. These state developments offer a powerful counter-paradigm to that of the U.S. Supreme Court, where persistent interpretive divides and a refusal to treat methodological statements as precedential have made interpretive consensus seem impossible. They also highlight that, for all the energy that the statutory interpretation wars have consumed, the legal status of methodology itself-whether it is "law" or something "less" - remains entirely unresolved. [ABSTRACT FROM AUTHOR]

The federal government is funding a sea change in health care by investing in interventions targeting social determinants of health, which are significant contributors to illness and health inequity. This funding power has encouraged states, professional and accreditation organizations, health care entities, and providers to focus heavily on social determinants. We examine how this shift in focus affects clinical practice in the fields of oncology and emergency medicine, and highlight potential areas of reform.

Litigation cannot solve a public health crisis. But litigation can be an effective complementary tool to regulation by increasing the salience of a public health issue, eliciting closely guarded information to move public opinion, and prompting legislative action. From tobacco to opioids, litigants have successfully turned to courts for monetary relief, to initiate systemic change, and to hold industry accountableFor years, litigators have been trying to push firearm suits into their own litigation moment. But litigation against the gun industry poses special challenges. Not only has the regulatory regime failed to prevent a public safety hazard, Congress has consistently underfunded and understaffed the relevant regulatory actors. And in 2005 it legislatively immunized the gun industry from suit with the Protection of Lawful Commerce in Arms Act (PLCAA).This paper surveys the field of litigation in response to gun violence, tracking the limited successes of victims and stakeholders suing the gun industry. We find that victories remain confined to individual actors and unlike high-impact public litigations in other areas, aggregate class actions and major public litigation led by state attorneys general are noticeably absent in the firearm context.

Importance: Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law's impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation., Objective: To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act., Design, Setting, and Participants: Quasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states., Interventions/exposure: Policy implementation in January 2014., Main Outcomes and Measures: Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation., Results: A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity-, age-, and sex-based disparities in which patients use rehabilitation., Conclusions and Relevance: This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states.

Background: The Affordable Care Act (ACA) changed the landscape of insurance coverage, allowing young adults to remain on their parents' insurance until age 26 (Dependent Coverage Provision [DCP]) and states to optionally expand Medicaid up to 133% of the federal poverty level. Although both improved insurance coverage, little is known about the ACA's impact on observed receipt of timely access to acute care. The objective of this study was to compare changes in insurance coverage and perforation rates among hospitalized adults with acute appendicitis "after vs before" Medicaid expansion and the DCP using an Agency for Healthcare Research and Quality (AHRQ)-certified metric designed to measure pre-hospital access to care., Study Design: We performed a quasi-experimental, difference-in-difference (DID) analysis of 2008-2015 state-level inpatient claims., Results: Adults, aged 19 to 64, in expansion states experienced an absolute 7.7 percentage point decline in uninsured (95% CI 7.5 to 7.9) after Medicaid expansion compared with nonexpansion states. This coincided with a 5.4 percentage point drop in admissions for perforated appendicitis (95% CI 5.0 to 5.8) that was most pronounced among young adults, aged 26 to 34, just age-ineligible for the DCP (DID: 11.5 percentage points). Medicaid expansion insurance changes were 4.1 times larger than those encountered under the DCP (DID: 1.9). They affected all population subgroups and significantly reduced access-related disparities in race/ethnicity and lower-income communities. Although both Medicaid expansion and the DCP were associated with significant insurance gains, those attributable to the DCP were more concentrated among more privileged patients. Despite this trend, both policies resulted in larger reductions in perforation rates for historically uninsured and underserved groups., Conclusions: Reductions in uninsured after Medicaid expansion and the DCP were associated with significant reductions in perforated appendix admission rates. Improvements in access to acute surgical care suggest that maintained/continued insurance expansion could lead to fewer delays, better patient outcomes, and reductions in disparities among the most at-risk populations., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)