The Supreme Court today decided Haaland v. Brackeen, a challenge to the Indian Child Welfare Act of 1978. It did not reach vital underlying Constitutional issues of equal protection and individual rights for children and families, and these remain to be resolved another day. Instead, the Court addressed important structural issues concerning the relationship between federal, state, and tribal governments. It interpreted the Constitution as giving robust powers to Congress to regulate Indian matters, while sharply limiting the underlying authority of state governments. It also found the doctrine of “commandeering” inapplicable to the facts here and denied some claims of standing. The 7–2 decision was written by Justice Amy Coney Barrett, with Justices Clarence Thomas and Sam Alito writing dissents and Justice Brett Kavanaugh a concurrence.

Future cases may frame more sharply than this one did such questions as whether children and parents who have never lived in tribal relations or in Indian country may nonetheless be subjected to tribal sovereignty and special custody presumptions because of blood descent alone. Cato raised some of these issues in its brief.

Everyone interested in these issues should read Justice Neil Gorsuch’s eloquent concurrence, joined in part by Justices Sonia Sotomayor and Ketanji Brown Jackson, in which he lays out the grim history of government intervention in Indian family life to which ICWA was a reaction. It is a history in which agents of the state intervened to take children away from the only families they had ever known, very much against those families’ will, to place them with complete strangers in pursuit of vague remedial goals. Some will see in this history above all an assault on Indian tribes as collective entities. Others — I am one — will be moved to horror above all by the flagrant violations of individual and family rights. We should take care not to repeat such violations in pursuit of new remedial objectives.

Any American who smoked pot in the 1970’s likely came across Colombian marijuana. In 1979, in fact, Colombia was providing “roughly two-thirds of all the pot smoked” in the United States, according to Time Magazine. The industry certainly was illegal, but it also arose from an exemplary instance of bicultural exchange and bilateral trade. It was, after all, American Peace Corps volunteers who came across the legendary “Santa Marta Gold” strain on Colombia’s Caribbean coast, thus kicking off the country’s decade-long “marijuana bonanza.”

The boom times for Colombian pot came to an end due to the onset of the War on Drugs—which President Nixon officially declared in 1971— and the rapid rise of indoor cannabis farming in the fifty states. Today, with nearly half of U.S. states having legalized recreational consumption, and with the end of federal prohibition perhaps in sight, is there any chance that Colombian cannabis can regain its former glory days—this time legally— in the American market? Much depends on if, when, and how federal prohibition is repealed, but also on Colombia’s capacity to reform its own byzantine drug laws.

A law approved in 1986 (no. 30) defined any quantity up to 20 grams of marijuana as the “minimum dose” for personal consumption, and it applied a series of criminal charges for its possession. In 1994, however, Colombia’s Constitutional Court ruled that no individual could be penalized for carrying said minimum dose. However, the law, which is still in effect, makes it a criminal offense to possess or carry a narcotic, “whatever its quantity, for the purpose of distribution or sale.”

As I wrote in Foreign Policy, the minimum dose rule provides a good example of Colombia’s trademark legalism: unless one grows cannabis oneself (more on which later), the only way to obtain a legal gram for personal consumption—or 20—is by buying it, illegally.

Eventually, local drug warriors would have their say. In 2009, former president Alvaro Uribe passed a Legislative Act (no. 2) which altered Article 49 of the constitution so as to prohibit “the possession and consumption of narcotic or psychotropic substances, unless prescribed by a medical doctor.” The following year, Uribe’s government introduced a bill (Law 248) that sought to regulate the legislative act and criminalize the minimum dose. The objective, professors Hernando Londoño and Adrian Restrepo argue, was to bolster the war against the drug cartels by targeting internal consumption. This latter initiative failed and the minimum dose was maintained. Nonetheless, by enshrining drug prohibition in the constitution, Uribe made any future reform of the country’s drug laws extremely difficult.

In 2015, when the government of former president Juan Manuel Santos sought to legalize medical marijuana, it had to resort to a decree (2467) that expanded on Law 30 of 1986. The decree regulated cannabis production for “strictly medical or scientific purposes.” While legalizing the medical use of marijuana was a step in the right direction, the local industry has been saddled by red tape.

For instance, physicians still are allowed to prescribe only manufactured cannabis-based products, not dry cannabis flower. Also, the use of CBD—a multibillion-dollar industry in the U.S.—is not allowed in Colombian food, beverages, supplements, or veterinary products. Since the local market has not been allowed to develop, local cannabis firms—including a few that raised funds in the U.S. and are even listed on the Nasdaq—are on the verge of bankruptcy. Potential investors, meanwhile, are eyeing other markets, and rightly so.

The black market, however, has thrived, not least because the 2015 decree allowed the “self-cultivation” of up to 20 cannabis plants for personal use without a license from the Health Ministry. Since each plant can produce around a kilo of marijuana, massive amounts of pot are grown legally, only to be transported and sold illegally. Which is to say, Colombian lawmakers have created the worst of all worlds for consumers and legal producers alike, this in spite of the industry’s immense potential to generate profits, jobs, and tax revenues.

But Colombia’s Congress now has a chance to unravel the marijuana muddle. A new Legislative Act, introduced by Representative Juan Carlos Losada, a member of the Liberal Party, seeks to insert an exception for adult, recreational cannabis consumption into Article 49 of the constitution. This would create a legal market to buy, sell, and distribute marijuana in Colombia. After being approved in seven debates in Congress, Losada’s project faces one final hurdle in the Senate on Thursday, June 15.

Legislators should approve the measure. Colombian conservatives should keep in mind that extreme leftist Gustavo Petro, the current president, did not bring forth the initiative (despite his supposedly revolutionary stance against the drug war). Hence, supporting marijuana legalization does not involve supporting the government. Center-right politicians also should remember the words of the great Alvaro Gómez, the conservative leader who warned as early as 1976 that the war on drugs was doomed to failure.

Regulating marijuana use for adults, on the other hand, implies seizing the local market from violent, criminal gangs and leaving it in the hands of the legal, regulated businesses that can assure quality, safety, and transparency. Eventually, when the United States and other countries open their markets to cannabis products from other latitudes, Colombia can regain its standing as a global exporting powerhouse. Far more than foreign aid handouts, the country could use a legal marijuana bonanza.

Last month, Rep. Jasmine Crockett (D‑TX) introduced the Secure Testing Resources Instead of Prosecuting (STRIP) Act. The act would clarify the language in the Controlled Substances Act that defines federally prohibited drug paraphernalia to make plain that “fentanyl drug testing equipment, including fentanyl test strips,” are not illegal. This would undoubtedly be a helpful, if small, step in removing government obstacles to people wishing to provide harm reduction tools to help the people in their community who use drugs obtained on the black market.

Federal drug paraphernalia laws make it illegal to sell, transport through the mail, import, export, or transport across state lines federally defined drug paraphernalia. State paraphernalia laws prohibit simple possession and intrastate transfer of state-defined drug paraphernalia.

As Sophia Heimowitz and I reported in our Cato policy analysis last year, drug paraphernalia laws undermine harm reduction efforts. In the late 1970s, the Drug Enforcement Administration encouraged states to enact these laws. Our study found that every state except Alaska passed them.

When Cato released our study, the great majority of states considered any equipment used to test illicit drugs, including fentanyl test strips, to be illegal drug paraphernalia. As state lawmakers have increasingly recognized that allowing people to test the drugs they obtain on the black market for the presence of fentanyl can be a true lifesaver, more states have amended their drug paraphernalia laws to legalize fentanyl test strips explicitly.

In our policy analysis, we argue for repealing all drug paraphernalia laws because they stand in the way of other proven harm reduction strategies, including syringe service programs (also called “needle exchange” programs) and overdose prevention centers. To their credit, lawmakers in Minnesota repealed the state’s drug paraphernalia laws last month. However, if full repeal is not politically feasible, the next best option is to amend the laws to remove as many obstacles to harm reduction as possible.

As I explained in testimony to members of the House Judiciary Subcommittee on Crime and Government Surveillance last March, the “iron law of prohibition”—the harder the law enforcement, the harder the drug—guarantees that doubling down on law enforcement of drug prohibition is not only futile, but it also promotes the cartels’ development of new and more potent drugs and drug combinations. I told the subcommittee that we are already seeing the iron law’s latest product, tranq (fentanyl infused with the veterinary tranquilizer xylazine), in growing numbers of overdose deaths, and I warned them that nitazenes might soon replace tranq.

Fortunately, the manufacturer of fentanyl test strips has now developed xylazine test strips. Alas, states that have amended their drug paraphernalia laws to permit fentanyl test strips must pass separate legislation allowing xylazine test strips. And when the next big drug takes the stage—maybe isotonitazene—lawmakers will need to introduce legislation legalizing nitazene test strips. As long as policymakers persist in prosecuting America’s longest war, the war on drugs, the iron law of prohibition guarantees there will always be a new and more potent drug to wage war against.

Here’s a suggestion to state lawmakers: if it is not politically feasible to repeal state drug paraphernalia laws, then at least make all drug testing equipment and devices legal. I have the same advice for Congress: change the wording of the STRIP Act from “fentanyl drug testing equipment, including fentanyl test strips” to simply state “drug testing equipment.”

While most barriers to harm reduction are caused by state-level drug paraphernalia laws, Rep. Crockett’s STRIP Act sends a message from Washington to state lawmakers that it is okay to allow black-market drug users to test for fentanyl. Congress can send state lawmakers an even stronger message by exempting any drug testing equipment from federal paraphernalia laws or, better yet, by repealing federal drug paraphernalia laws altogether.

Suddenly, and rather quietly, both public and elite opinion are turning against the “new” methods of teaching reading that have dominated our schools for a generation.

I’ve been keeping an eye on this issue for a long time. In 1995 I noticed that after state test results showed that the vast majority of California public school students could not read, write, or compute at levels considered proficient, Superintendent of Public Instruction Delaine Eastin appointed two task forces to investigate reading and math instruction. The reports were clear — and depressing. There had been a wholesale abandonment of the basics — such as phonics and arithmetic drills — in California classrooms. Eastin said there was no one place to lay the blame for the decade‐​long disaster. “What we made was an honest mistake,” she said. Or as the Sacramento Bee headline put it, “We Goofed.”

You’d think such a devastating report in the nation’s largest state would have had an impact. But it didn’t seem to get much attention outside California. Instead, schools kept adopting reading instruction plans based on “whole language” and “balanced literacy” theories. Despite the fact that in 1997 Congress instructed the National Institute on Child Health and Human Development to work with the Department of Education to establish a National Reading Panel that would evaluate existing research and evidence to find the best ways of teaching children to read. The panel reviewed more than 100,000 reading studies. In 2000 it reported its conclusion: That the best approach to reading instruction is one that incorporates:

• Explicit instruction in phonemic awareness
• Systematic phonics instruction
• Methods to improve fluency
• Ways to enhance comprehension

But suddenly, in May of last year the New York Times took note of the problems with school reading instruction with a page 1 article on how a leading advocate of “balanced literacy” was backtracking. At Columbia University’s Teachers College, she and her team trained thousands of teachers, and she estimated that her “Units of Study” was used in a quarter of the country’s 67,000 elementary schools.

The Times noted that a 2019 investigation by American Public Media revealed “American education’s own little secret about reading: Elementary schools across the country are teaching children to be poor readers — and educators may not even know it.”

Then in January of this year I noted that the Fairfax County and Arlington County NAACP chapters in Virginia were making demands on the local school system: they want the schools to teach black and Hispanic kids to read. And they want the school to start using the best research‐​tested methods. After years of promising to make minority achievement a priority, finally in the past school year, the district gave all kindergarten through second‐​grade teachers scripted lesson plans featuring phonics.

In March the Washington Post editorialized: “Cut the politics. Phonics is the best way to teach reading.”

In April the New York Times reported, “A revolt over how children are taught to read, steadily building for years, is now sweeping school board meetings and statehouses around the country.” They quoted Ohio Governor Mike Dewine: “The evidence is clear,” Mr. DeWine said. “The verdict is in.” And noted: “The movement has drawn support across economic, racial and political lines. Its champions include parents of children with dyslexia; civil rights activists with the N.A.A.C.P.; lawmakers from both sides of the aisle; and everyday teachers and principals.”

American Public Media has continued to follow the issue, and reported recently that at least 18 state legislatures are considering “ways to better align reading instruction with scientific research.”

NPR’s “All Things Considered” reported in June on the state of Georgia’s new push for phonics in the lower grades. NPR notes that “there’s perhaps no greater predictor of how a child will succeed in school than how well they can read by about the third grade. Research has shown that if students don’t learn by then, they’re far more likely to fall dangerously behind.”

This new approach is being called “the Science of Reading,” but it’s the science your grandmother knew: Learn the letters, learn how each letter sounds, learn how the letters combine into words. The amazing thing is that for a generation or more, professors and school administrators thought they had better ideas.

As I wrote before:

Phonics seems like a good idea to me, but I’m no expert. As noted, though, there’s a lot of research recommending phonics that a lot of school districts still aren’t following. As a libertarian, I don’t usually spend much time telling government agencies how to do their jobs, except as their actions impinge directly on individual rights. My focus is more on defining what activities ought to be undertaken by government and what ought to remain in the private sector, with individuals, businesses, churches, clubs, nonprofits, and civil society. And I think there’s a lesson here on that.

Government agencies tend to be sluggish monopolies, with little incentive to improve and subject to political influence. When the California superintendent promised to fix the mistake, the teachers union head warned, “It’s like turning an oil tanker around. You just don’t do that quickly,” and the governor’s spokesperson said it would be a hard slog because “there is such partisan politics going on.” Private organizations, especially profit‐​seeking businesses, are under constant pressure to serve customers better than their competitors. Businesses fail to meet that test every day and go out of business. When’s the last time you heard of a failed government agency being shut down? That includes schools. Private schools must keep families happy or they can go elsewhere, and the school could be forced to shut down. Public schools, no matter how unhappy parents are, are almost never closed. As long as the tax money keeps coming in, they stay in business.

The problem is that the schools are run by a bureaucratic government monopoly, largely isolated from competitive or community pressures. We expect good service from businesses because we know–and we know that they know — that we can go somewhere else. We instinctively know we won’t get good service from the post office or the Division of Motor Vehicles because we can’t go anywhere else.

But now, after many years of complaints from parents, the elite media are joining the chorus: Teach children to read, using time-tested methods, confirmed by the National Reading Panel in 2000. It’s about time.

Last weekend the American Medical Association House of Delegates passed a resolution tacitly claiming that the National Residency Matching Program (NRMP) is likely anti-competitive and a violation of the Sherman Antitrust Act of 1890. The resolution concluded:

RESOLVED, That our American Medical Association study alternatives to the current residency and fellowship Match process which would be less restrictive on free market competition for applicants. (Directive to Take Action)

This is quite surprising, given that the AMA was a co-defendant, along with the Association of American Medical Colleges (AAMC), the Accreditation Council for Graduate Medical Education (ACGME), the American Hospital Association (AHA), and several teaching hospitals in a 2002 antitrust class action lawsuit brought by Dr. Paul Jung (Jung v. AAMC) on behalf of current and former residents.

As Eastern Virginia Medical School Professor Bryan Carmody explains in his blog and this very well-produced video, the NRMP system established in the 1950s has since been the only way that medical school graduates may seek positions in residency programs. The program was established by the AAMC and National Student Internship Committee and supported by the AMA. It provides a centralized application process that matches applicants with residency programs using a mathematical algorithm designed to maximize the preferences of both parties. The NRMP eliminated and replaced the process where medical school graduates negotiated residency positions and salaries at various institutions. The NRMP ended any negotiation process. Each residency program participating in the NRMP pays all its residents in all specialties the same salary. Medical school graduates have no other options for seeking residency positions outside the NRMP.

Dr. Jung and co-plaintiffs argued that all this violates antitrust law. Many legal scholars believed the plaintiffs had a strong case as their lawsuit moved forward. As the defendants’ prospects of acquittal began to fade, the AMA and the NRMP engaged in a public relations campaign to “save the match.” Eventually, the AAMC, AHS, and the AMA lobbied successfully to get Congress to attach a last-minute rider–without debate–to the 2004 Pension Funding Equity Act, co-sponsored by Senators Edward Kennedy (D‑MA) and Judd Gregg (R‑NH). The rider, entitled “Confirmation of Antitrust Status of Graduate Medical Resident Matching Programs,” exempted the NRMP from the Sherman Antitrust Act:

It is the purpose of this section to—

(A) confirm that the antitrust laws do not prohibit sponsoring, conducting, or participating in a graduate medical education residency matching program, or agreeing to do so; and

(B) ensure that those who sponsor, conduct or participate in such matching programs are not subjected to the burden and expense of defending against litigation that challenges such matching programs under the antitrust laws.

Every state and the District of Columbia require medical school graduates to complete at least one year of a residency program (residency programs range from 3 to 7 years) and pass Step 3 of the standardized national licensing exam (USMLE for MDs and COMLEX for DOs) to get a license to practice as a general practitioner. As Cato Research Associate Spencer Pratt and I detail in our recent policy brief:

Since the early 1950s, hospitals and medical centers that offer postgraduate training (residency) programs have been participating in the National Resident Matching Program (NRMP), which matches graduating medical students with available residency programs. Many medical school graduates do not match with positions in accredited programs because the number of residency slots available has not increased at the same rate as the number of medical students. The graduates are stuck in limbo, unable to apply the knowledge and clinical skills acquired with their doctorate degrees to care for patients while also being unable to further hone and develop those clinical skills with postgraduate training. According to the American Medical Association, in 2021, roughly 7 percent of doctor of medicine graduates and 10 percent of doctor of osteopathy graduates found themselves in that state of limbo.

Our brief discusses how Missouri lawmakers addressed this problem by licensing a new category of health care practitioner called Assistant Physician (AP). Already having received their doctorates in medicine, these graduates are essentially apprentice physicians. They work under the supervision of collaborating licensed medical doctors. Missouri launched this innovation in 2017. Missouri allows APs to annually renew their licenses without limits.

Since then, several other states have followed Missouri’s lead by enabling APs to render primary care services to patients. Unfortunately, unlike Missouri, under intense lobbying from state chapters of the American Academy of Family Physicians (AAFP) and the American Medical Association, lawmakers in those states have limited the number of times an AP may renew a license. In some cases the AP license is only good for one year. The AAFP and AMA have convinced many state lawmakers that an AP should only serve as a “bridge year” to allow medical school graduates an opportunity to gain experience and income while waiting to enter the next year’s match. Idaho, for example, only grants a one-year, non-renewable license to APs.

The recent AMA resolution calls for the organization to study alternatives to the current matching system that “would be less restrictive on free market competition for applicants.”

We agree. In the “Recommendations” section of our policy brief, Spencer Pratt and I state:

State lawmakers should enable medical school graduates to use their experience as APs as an alternative pathway to unrestricted licensure as GPs. If one or two years of residency plus passing Step 3 of the USMLE qualifies physicians in most states to practice medicine as GPs, then three or more years of experience as an AP and passing the same exam should suffice as well.

The AP to GP alternative pathway could lead to innovations in how specialty boards certify clinicians. For example, GPs who wish to specialize nowadays apply to specialty residency training programs. When they complete residency training, they take standardized specialty examinations and seek certification from specialty boards such as the American Board of Internal Medicine, the American Board of Family Medicine, the American Board of Pediatrics, and the American Board of Obstetrics and Gynecology. Thus, increasing the number of GPs might incentivize some certifying organizations to develop alternative pathways to certification that place greater emphasis on real‐​world experience. Certifying organizations might even develop various levels of certification based on applicants’ backgrounds and experience.

Increasing the supply of APs and, in turn, GPs, while promoting innovation in specialty certification would increase primary health care access and choice.

If the AMA seriously seeks redemption from its past anti-competitive transgressions, supporting this alternative pathway would be a good place to start.

The indictment itself is clear, well organized, and not too long. You should read the whole thing if you aim to be informed about this important moment in American history.

A few observations:

• Trump didn’t get charged with illegal possession over the 197 documents he gave back to the Archives voluntarily. That matches up with how Biden and Pence were treated after retaining some documents. Give back when asked = no rap, at least for officials at this level. Trump is facing charges because he chose to lie to the feds and hide documents.
• A substantial portion of the indictment lays out the reasons to think that lying to federal law enforcers and hiding documents was Trump’s purposeful course of action, not the result of some sort of carelessness or inattention.
• During his service as President, Trump was shockingly careless and self-centered in his handling of national security secrets. But his legal right to act that way ended when his term in office did.
• There are some pretty squirrely claims making the rounds about what the Presidential Records Act does and does not require. This explanation from the National Archives helps clarify matters. In brief: presidents are legally required to turn over all documents relating to their work in office, whether or not related to national security; the obligation attaches at the time their term ends; there isn’t any sort of further negotiation period. More from Andrew McCarthy and Ed Whelan.
• Trump himself has not consistently sought to hold with a theory embraced by some of his followers that a President can declassify documents with legal effect by winking at them or just thinking a mischievous thought, whether or not he then initiates any formal process or documentation to notify others in government. At any rate, the issue is largely irrelevant to the various charges in the indictment. The counts on willful retention of national security information do not require that the information be classified; the obstruction and concealment counts do not either (the grand jury had asked for all documents with classification markings, whatever their current classification status).
• Another substantial portion of the indictment lays out the reasons to think that even after federal agents had confronted him with the issue of illegally retained national security documents, Trump behaved in ways that compromised the security of the documents that he retained, some of which were of high seriousness for national security and bore very highly restricted secrecy markings. His storage arrangements were extraordinarily shoddy and included box storage in rooms frequented by random persons including a bathroom, shower, ballroom, storeroom, office, and bedroom. According to testimony and an audiotape, he showed sensitive security documents to civilian visitors.
• Trump’s former position required him to know, and the statements listed on page 9 of the indictment prove that he did know, the importance to national security of keeping secure the sorts of information at stake here. In addition, notes Oona Hathaway of Yale Law, Trump’s “own Justice Department vigorously enforced the Espionage Act, sending people to prison for much less than the actions described in the indictment of Mr. Trump.”

With so many people obtaining Medicaid coverage in the wake of the Affordable Care Act and during the pandemic, it is worth investigating whether this expanded eligibility is improving health outcomes. Overall, decreases in the proportion of uninsured individuals over the last decade are not being matched by improved life expectancy. Indeed, life expectancy at birth in 2021 was lower than it was when the Affordable Care Act passed. But this fact tells us little about the benefits of Medicaid coverage since the decline has been driven in large part by COVID-19 deaths among elderly patients (often not on Medicaid) as well as increased mortality from accidents and drug overdoses.

To better gauge the benefits of Medicaid, it is necessary to look at more specific health indicators. The federal Center for Medicaid and CHIP Services (CMCS) compiles a large variety of healthcare quality measures that could help us analyze outcomes. Unfortunately, most of these measures are not available for all states and all years, making it difficult to assess performance in a systematic way.

One indicator that is generally available is the rate of low birth weight, which is the percentage of newborns weighing less than 2500 grams, or about five pounds eight ounces. Low birth weight (LBW) babies have “a higher risk of morbidity, stunting in childhood, and long-term developmental and physical ill health including adult-onset chronic conditions such as cardiovascular disease.” Consequently, reducing the incidence of LBW should improve public health, but Medicaid services are not achieving this outcome.

A 2019 study in JAMA found no correlation between Affordable Care Act Medicaid expansion and LBW. The authors used administrative records to obtain rates of LBW (and some other adverse birth outcomes) before and after Medicaid expansion in states that accepted the expansion and those that did not. The change in LBW rates in expansion states was not significantly different than that in non-expansion states. The authors did find some improvement for Black infants in expansion states, but not for white or Hispanic infants.

Overall, the US is not among the countries that have had the best success in minimizing low birth weight. A 2015 World Health Organization analysis ranked the US 64^th among 146 countries, with such less affluent nations as Albania. China, and Cuba performing better. Poor US outcomes have been attributed to the use of fertility drugs (which increases the likelihood that a mother will give birth to twins or triplets) and the high rate of Caesarian sections.

According to data from the CDC WONDER Database, 8.3% of US babies born in 2019 were low birth weight. The LBW rate among Medicaid patients was substantially higher, coming in at 9.8% (WONDER also has 2020 and 2021 data, but I chose 2019 data to avoid any pandemic-related affects).

In the District of Columbia, the LBW disparity between Medicaid-financed births and those with other types of coverage is especially stark. In 2019. DC’s overall LBW rate was 9.9%. For Medicaid births, it was 12.7% and for non-Medicaid births it was only 7.4%. And, it does not appear that this disparity is caused by a lack of access to government-paid medical services: the Medicaid and CHIP Payment and Access Commission (MACPAC) reports that (in 2018) 99.3% of DC Medicaid births took place in a hospital and that 91.7% were attended by a physician, with almost all of the remainder attended by a Certified Nurse Midwife.

The risk of low birth weight can be minimized through proper nutrition, not smoking, and avoiding narcotics. These risks can be controlled with non-medical interventions. For example, at-risk mothers can be accommodated at maternity homes, where their diet and substance use can be carefully supervised. The widespread use of maternity homes in Cuba may explain the low rate of LBW in that country (although Cuba’s health statistics have been subject to criticism).

WONDER provides statistics on tobacco use in pregnant women. In DC, the LBW rate among Medicaid tobacco users was 23.7%. Unfortunately, data are not available for other types of substance abuse or malnutrition, however Wallethub recently ranked DC’s drug use fifth among all states (plus DC).

Some states are devoting Medicaid resources to the “social determinants of health”, funding non-medical services such as housing and nutrition that are intended to address health inequities. DC has an Office of Health Equity that supports “projects, policies and research that will enable every resident to achieve their optimal level of health — regardless of where they live, learn, work, play or age.” But these added efforts are not making a dent in LBW.

Despite spending over $3 billion on Medicaid annually, DC (like other parts of the US), has pregnancy outcomes that are on a par with or even below those of developing countries. It appears that providing costly pregnancy services cannot substitute for the basic health precautions we hope all expectant mothers will take.