John Colbert

January 22, 2019

HEALTH REFORM DEVELOPMENTS

John Colbert

January 22, 2019

It does not amount to the least bit of hyperbole to suggest that a great many pieces of legislation that are enacted into law might conveniently be subtitled: The Attorneys, Accountants, and Lobbyists Relief Act (fill in the year of enactment). The Patient Protection and Affordable Care Act of 2010 (commonly referred to as either the ACA or Obamacare) fits this description perfectly. To cite just one example, in February last year, 20 attorneys general filed a lawsuit claiming that the 2017 Tax Cut law and the Jobs Act’s reduction of the individual responsibility tax penalty to zero, in effect made the ACA’s individual mandate unconstitutional. Proceeding from that line of reasoning, it means that the entire ACA was invalid because of the disappearance of the tax penalty. In December of 2018, a federal court judge in Texas agreed with this argument, entering a judgment that if it is upheld, the entire ACA would become invalidated. What comes as no surprise is that supporters of the Affordable Care Act have mounted their opposition to this ruling. Democratic attorneys general in 17 states have intervened to defend the entirety of the health reform law.

Apart from this specific example, it is worth noting that once it became apparent that Republicans in Congress in 2017 were unable to repeal and replace the ACA, since then the Trump Administration has used its powers to issue several regulations and guiding principles aimed at crippling the law. Opponents have responded by unleashing countersuits to prevent or delay these administrative actions. Thus, it is safe to assume that the future appears to remain quite bright when it comes to the financial health of many law firms and advocacy groups since additional litigation already can be detected hovering on the near horizon.

Administration Initiative To Create Association Health Plans Faces Challenges
One Trump Administration regulatory initiative is aimed at creating Association Health Plans that do not have to comply with either ACA individual or small-group requirements, In June 2018, the Labor Department finalized a rule to expand the ability of employers, including sole proprietors without common law employees, to join together and offer health coverage through Association Health Plans. These short-term limited duration vehicles can be in effect for one year and also be subject to renewal for as many as 36 months while continuing to be exempt from the Affordable Care Act’s consumer protections. Opponents have reacted in New York and other states by bringing a lawsuit to challenge the health plan rule on the basis that it violates the ACA, the Employee Retirement Income Security Act (ERISA) of 1974 that regulates group health plans, and the Administrative Procedures Act. Oral arguments in federal district court for the District of Columbia were scheduled to begin in January 2019.

Transgender Protections And Religious/Moral Objections To Contraception Coverage
Increased attention is being paid by policymakers to the issue of whether the health care needs of transgender individuals are being addressed satisfactorily. One concern is whether current regulations provide adequate protection from discrimination against transgender patients by insurance companies and health care providers. Federal courts have weighed in on this matter in the past and can be expected to continue doing so in the future. Mandated benefits under the ACA sometimes trigger opposition for moral and religious reasons. Contraception coverage offers an example whenever religious groups are compelled to provide this benefit because doing so may conflict with core spiritual beliefs.

Pursuing The Realization Of Health Care Priorities In Congress
Major differences exist between Democrats and Republicans in Congress, and despite that each party enjoys a majority in only one chamber, it still may be possible to achieve bipartisan agreement on certain issues that could be enacted into law. An example is lowering the cost of prescription drugs. President Trump also has signaled his desire to see constructive action taken in that regard. Recent years have involved a series of proposed buy-outs and mergers among drug companies, insurance firms, and health care providers. Through its oversight powers, committees in Congress may be able to work in an effective bipartisan way to determine if such transactions have the potential either to weaken competition or have a negative impact on health care consumers and taxpayers. Fixing a maldistribution of health resources in the form of an insufficient supply of clinicians and health care facilities in rural areas is a chronic problem that also should be of interest to legislators from both political parties.

Return to Dec 2018 - Jan 2019 trends

FEDERAL BUDGET AND THE OPERA

John Colbert

January 22, 2019

Trends Archives

An inability to reach agreement on federal budget priorities resulted in a partial government shutdown to mark the start of the year 2019. The current shutdown occurred because of an inability to reach agreement on how much should be spent and for what purposes to increase security measures along the nation’s southern border with Mexico. This 21st stoppage in the past 43 years conjures up thoughts about how efforts to produce a budget each fiscal year can assume qualities of an operatic nature. As an illustration, divas and divos from both major political parties are accustomed each year to performing dramatic roles involving the equivalent of singing enthusiastic arias that reflect their distress at pet projects being denied adequate funding.

History shines some light on the nature of the basic problem. Only on four occasions since 1977 has Congress been able to pass all 12 appropriations bills on time before a new fiscal year begins on October 1. Another 16 years have been characterized by an inability to pass a single bill on time. The usual remedy is to enact short-term continuing resolutions (CRs) to enable the government to continue operating, but as the present situation exemplifies, even that approach has not been possible on 21 different occasions.

It also is worth acknowledging that squabbles over the federal budget are restricted to only one-fourth of total spending. Referred to as discretionary expenditures, amounts have to be debated and agreed upon for purposes, such as aid to education, the military, National Institutes of Health, and the provision of agricultural subsidies. The remaining three-fourths of the budget essentially is on automatic pilot where spending is allocated among major entitlement programs, including Social Security and Medicare. Once individuals qualify to become recipients, their benefits must be paid as regularly as clockwork. Given the steady numerical and proportional growth in the segment of the population age 65 and older, the provision of adequate support for such programs will continue to pose significant future challenges.

Apart from funding, individual members of Congress either singly or in combination will introduce a large number of bills in 2019. Committees and subcommittees will conduct hearings and also carry out oversight activities of the executive branch. The educational community has been waiting patiently since 2013 for reauthorization of the Higher Education Act (HEA). This major piece of legislation that became law in 1965 last was reauthorized in 2008. Whether agreement can be reached on producing a reauthorization this year remains to be seen.

Both chambers are off to a quick start proposing other legislative action.

Senate:
S.3—stabilize the individual insurance market, make insurance coverage more affordable, lower prescription drug prices, and improve Medicaid.
S.12—improve access to health care through expanded health savings accounts.

House:
H.R. 64—intensify stem cell research showing evidence of substantial clinical benefit to patients, and for other purposes.
H.R. 83—repeal the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010.

Now that Democrats are the majority in the House of Representatives, considerable interest is being expressed in moving toward a single payer system. Expanding Medicare eligibility to a wider segment of the U.S. population would be a step in that direction.

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PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

John Colbert

January 22, 2019

Trends Archives

By Susan N. Hanrahan, ASAHP President

In my message in the November 2017 issue, I indicated that I will be asking some of you to send a photo and answer a series of “fun” questions to be shared with our membership so that we can continue our collegiality through our newsletter. The 9th of many profiles and the first in 2019 is presented as follows:

Name and Title: Brooke Hallowell, Dean of Health Sciences and Rehabilitation Studies

University: Springfield College

How long have you been in your position? 1 year

If I could teach in another field, which one and why? Counseling/coaching/hypnotism. To be at the heart of empowering people to be their best, authentic selves, thus enhancing their roles as vehicles of service to others.

Before I retire I want to: Start doing a lot of the things I dream of doing after I retire.

In college, I was known for: Being president of our university orchestra.

What music is playing in my car/office? Francis Cabrel

My favorite trip was: In southern India, with my daughter

If I could travel anywhere it would be: Fiji

The best advice I ever received was: Put on your own oxygen mask before assisting others.

My hobby is: Improv acting, arm wrestling, sculpting, collaborative storytelling

My passion is: Hanging out with older people and babies.

Beach or mountains? Both! Why choose?

Only my friends know I: Am a certified heavy equipment operator and an arm-wrestling pro.

My favorite saying is: Choose the joy!

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CALLING UNCLE SAM AND ALEXA

John Colbert

January 22, 2019

Trends Archives

Federal programs that include Medicare and Medicaid, along with technology developments in the private sector such as Alexa are two sets of forces that represent enormous influences on the health care domain. Apart from furnishing health services and paying for them, parallel activities by other government entities play essential roles in generating innovations (e.g., National Institutes of Health) and ensuring safety of new health products (e.g., Food and Drug Administration).

The Medicare Board of Trustees reported on June 5, 2018 that in 2017, Medicare covered 58.4 million individuals, 49.5 million aged 65 and older, and 8.9 million who are disabled. Total expenditures in 2017 were $710.2 billion and total income was $705.1 billion. Medicaid is the nation’s public health insurance program for individuals with low income. It covers more than 70 million Americans, including many with complex and costly needs for care. The program accounts for one in six dollars spent on health care in the United States and more than half of all spending for long-term services and supports. Plus, it drives state budgets and is the largest source of federal revenues to states.

Amazon Echo and Dot devices are improving patients’ lives by enabling those who are bedridden and unable to reach a wall thermostat to regulate room temperature. When issuing commands to a device, the software can be rearranged to accommodate whatever words a patient is capable of using to perform various household tasks and set medication reminders. An Alexa app called Marvee can translate voice snippets into text messages and deliver them to pre-specified contacts. Meanwhile, Amazon has filed a patent for the Alexa voice assistant to recognize coughs or colds. That firm also has been exploring options that would allow it to mine medical records to diagnose patients and it has been exploring the possibilities of testing patients for disease at home.

Technology developments impinge on the government both directly and indirectly. For example, the Apple Watch can generate data as a consumer health tracker. The company touts the ability of this device to detect atrial fibrillation, although evidence is gathering that it does so less accurately for users below the age of 55. Efforts currently are underway to determine if private Medicare plans are interested in subsidizing the watch for beneficiaries.

As devices of this nature collect consumer and patient health information, concerns are raised about how adequately current policies protect privacy. Congress could play a useful role by clarifying the amount of authority and ownership patients have over their own records, and the extent to which patient information can be held by a health system. Steady advances in germline gene editing and artificial intelligence also call into question whether existing policies suffice to ensure that patients are protected from possible harm. A congressional in-house think tank, the Office of Technology Assessment (OTA), was disbanded in 1995. As legislators increasingly are called upon to deal with technology issues, restoring the OTA may be warranted as a means of assisting them to perform satisfactorily.

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NAVIGATING THE HEALTH FRONTIER

John Colbert

November 26, 2018

Trends Archives

A deeper understanding of consumers’ decision-making processes can equip health care providers to retain and engage them effectively as well as attract new ones. The Deloitte Center for Health Solutions recently surveyed 4,530 U.S. consumers to assess their attitudes, behaviors, and preferences when making decisions about health insurance, health care, and well-being. A segmentation analysis of data, focusing on health care attitudinal and behavior questions rather than demography, offered a richer understanding of consumers than analysis focused solely on demographic factors.

The analysis categorized individuals into four distinct groups that reflect their differences in preferences for managing their health and interacting with various providers. Given its changing and sometimes unknown landscape, the U.S. health care system draws parallels with the Wild West of the 19th century. Personalities of individuals from the American frontier during that time period used to describe the results of segmentation are as follows:

Trailblazers (tech-savvy, self-directed, engaged in wellness, willing to share data)
Prospectors (rely on recommendations from friends/family, use providers as trusted advisors, willing to use technology)
Homesteaders (reserved, cautious traditionalists)
Bystanders (complacent, tech-reluctant, resistant to change, unengaged)

The analysis shows that each group not only has unique needs and expectations, but navigates the health care system differently. Segmentation findings can help tailor more effective interactions with consumers.

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CELEBRATING ALLIED HEALTH WEEK AT DES MOINES UNIVERSITY

John Colbert

November 26, 2018

Trends Archives

Members of Des Moines University Health Leaders and UnityPoint Clinic staff came together to celebrate Allied Health Week on November 8.

As part of 2018 Allied Health Week on November 4-10, the Des Moines University Health Leaders, an interprofessional student club, brought to campus members of UnityPoint Clinic’s recruitment staff on November 8. They held mock interviews with more than 30 physical therapy, physician assistant, and osteopathic medical students to help them hone their interviewing skills and resumés. The UnityPoint team also gave a presentation on general tips for constructing a strong resumé, the process that occurs from applying for a position to landing an interview, how to come prepared, and insights on contract negotiations. Additional events involved hosting a noon event for students to learn about each program on campus and networking on another evening that week.

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AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

John Colbert

November 26, 2018

Trends Archives

Separate & Unequal Public Colleges
America’s selective public colleges should be among the great equalizers in U.S. society. Funded primarily by taxpayers and carrying a relatively low price tag, these colleges are meant to be engines of opportunity for all. In reality, however, the doors of these institutions are open wider to White students than to their Black and Latino peers, according to a report from Georgetown University’s Center on Education and the Workforce. Whites have almost two-thirds (64%) of the seats in selective public colleges even though they make up barely half (54%) of the nation’s college-age population. Blacks and Latinos are making unprecedented gains in college-going, but the vast majority of Black and Latino students enroll in overcrowded and underfunded open-access colleges, primarily community colleges. Consequently, fewer Black and Latino students receive a bachelor’s degree. Selective public colleges reflect the Latino college-age population (18-to-24-year-olds) in just one state: Florida. Meanwhile, other states are far from parity. In California, 48% of the college-age population is Latino, but only 25% of students in selective public colleges are Latino. Blacks are not proportionately represented in selective public colleges in any state. Certain states are egregiously unbalanced, e.g., in Alabama, 32 of every 100 college-age residents are Black, but only seven of every 100 students at the state’s selective public colleges are Black. The report can be obtained here.

Access To High School Courses That Help Prepare Students For College
Students in relatively poor and small schools had less access to high school courses that help prepare them for college, according to an analysis of Department of Education data for school year 2015-16 (the most recent available) by the Government Accountability Office (GAO). While most public high schools, regardless of poverty level, offered courses like algebra and biology, disparities in access were associated with school poverty level for more advanced courses like calculus, physics, and those that may allow students to earn college credit, like Advanced Placement (AP) courses. High-poverty schools were less likely to offer the math and science courses that most public 4-year colleges expect students to take in high school, according to GAO's analysis of college websites. Regression analysis also showed that smaller schools and certain types of schools, like charter schools, are less likely to offer the college preparatory math or science courses that many colleges look for during the admissions process. The report can be obtained here.

Understanding Disparities In Access To Genomic Medicine
Genomic medicine has the potential to improve the quality of health and health care by allowing clinicians to tailor prevention and treatment strategies individually to their patients. Recent research breakthroughs, technological advances, and the decreasing cost of DNA sequencing have led to wider adoption of genomic medicine in health systems. It is not clear, however, if genetic/genomic services will reach all communities within the population both now and in the near future because of a significant gap in knowledge regarding potential health care disparities in genomic medicine and precision health. The National Academies of Science, Engineering, and Medicine hosted a public workshop on June 27, 2018 that explored disparities in access that exist across different communities (e.g., in medically underserved areas and populations, across different racial/ethnic groups, and socioeconomic levels). Discussions included exploring barriers to accessing genomic/genetic services, the role of health systems in delivering equitable access, and innovative solutions and models of success in reducing health care disparities related to genomic medicine. Workshop proceedings can be obtained here.

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

John Colbert

November 26, 2018

Trends Archives

Use Of Yoga, Meditation, And Chiropractors Among U.S. Adults: 2012-2017
A report from the National Center for Health Statistics (NCHS) in November 2018 examines changes over time in the percentage of adults who used yoga, meditation, and chiropractors in the past 12 months, as well as variation by sex, age, race, and Hispanic origin. Among adults aged 18 and over, increases were seen from 2012 to 2017 in the use of yoga, meditation, and chiropractors. Yoga was the most commonly used complementary health approach among U.S. adults in 2012 (9.5%) and 2017 (14.3%). In 2017, women were more likely to use yoga, meditation, and chiropractors in the past 12 months compared with men. Non-Hispanic white adults were more likely to use yoga, meditation, and chiropractors compared with Hispanic and non-Hispanic black adults. In 2012, seeing a chiropractor was as popular as yoga, followed by meditation, but in 2017, meditation became the 2nd most-used approach ahead of chiropractic.

Increasing Medication Adherence Could Improve Care And Save Health Care Costs
Non-adherence to medication represents a major problem that limits the effectiveness of treatment and adds to the burden of illness and cost of health care. About half of all patients do not take their medication as prescribed, according to a September 2018 report from the National Council for Behavioral Health’s Medical Director Institute. Estimates indicate that medication non-adherence costs the health care delivery system $100 billion to $300 billion annually due to more frequent use of high-cost services, additional prescriptions to offset non-adherence, and interventions to address relapses. The report discusses medication non-adherence in chronic conditions, mental health, and substance use disorders, and offers some possible solutions. If many of these solutions were to be adopted by 2025, a projection is made that the health system would save $2 billion a year from reduced hospital costs alone. Apart from improving communication between patients and providers, some more high-tech solutions include apps and robots.

HEALTH TECHNOLOGY CORNER

Robotic Arm May Help To Rehabilitate Chronic Stroke Victims’ Communication Deficits
Apropos of the article about silos in Health Silo Disruption and Eradication of this issue of TRENDS, treatment in one domain (motor function) may benefit performance in another untreated domain (communication) in individuals with acquired aphasia, the loss of ability to understand or express speech. Research published in Frontiers in Neurology on October 22, 2018 shows that robotic arm rehabilitation in chronic stroke patients with aphasia may promote speech and language function recovery. The rehabilitation in this study targeted the right arm since study participants each had suffered a left hemisphere stroke leading to a deficit in motor function on their right side. The research team observed small, but consistent improvement on measures assessing speech articulation and overall language processing in aphasia. It is believed some treatment approaches may encourage plasticity and reorganization that can span multiple domains. Although this initial finding should be interpreted cautiously, it remains exciting to consider the possibility that stroke rehabilitation in one domain would improve performance in another domain.

Obesity Provides Unexpected Enhancement Of Anticancer Medications
Obesity is associated with increased mortality and reduced longevity, but counter-intuitive findings occasionally suggest evidence of an obesity paradox. An article published in the journal Nature Medicine on November 16, 2018 indicates that overweight patients sometimes respond better than other patients to powerful drugs that harness the immune system to fight tumors. Called checkpoint inhibitors, the drugs block the activation of PD-1, a protein on the surface of immune sentinels called T cells. The body naturally triggers PD-1 to dampen immune responses, but tumors also can stimulate PD-1 to protect themselves. Lifting this molecular “brake” allows the T cells to attack the cancer cells. PD-1 inhibitors have caused untreatable tumors to vanish for years in patients with melanoma, lung cancer, and some other cancer types. Although there is heightened immune dysfunction and tumor progression, there also is greater anti-tumor efficacy and survival after checkpoint blockade that targets some pathways activated in obesity.

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DEVELOPMENTS IN HIGHER EDUCATION

John Colbert

November 26, 2018

Trends Archives

The potential impact on health policy that might result from Democrats becoming the majority in the U.S. House of Representatives as a result of the mid-term elections earlier this month is described in Election Results to Ponder of this issue of TRENDS. The current page extends the discussion to consider how the education sphere also might be affected during the next two years. For example, Betsy DeVos, Secretary of the Department of Education, has been the target of steady criticism by Democrats since her appointment. One reason is her efforts to undo regulations from the Obama-era aimed at holding colleges accountable for the federal-loan debt of their students. She now can expect to be the object of tougher scrutiny by House Democrats.

Regulations proposed on November 16, 2018 that can determine how colleges handle cases of sexual misconduct under Title IX, the federal law meant to ensure gender equity on campuses, are destined to generate spirited opposition. Similarly, efforts by the Department to modify various regulations that deal with accreditation are destined to create a similar level of opposition. Meanwhile, an all-important Higher Education Act (HEA) continues to await reauthorization. Emboldened by their recent gains in the House of Representatives, combined with the prospect that they also might reacquire control of both the Senate and the White House in 2020, may provide an incentive for Democrats to wait until then to reauthorize the HEA. That way, they would be in a more advantageous position to produce legislation in line with their policy objectives.

Proposed Regulations On Title IX Campus Sexual Assault
The U.S. Department of Education on November 16 issued a long-awaited notice of proposed rulemaking (NPRM) to specify additional regulations to implement Title IX of the Education Amendments of 1972. The NPRM procedure is required by the federal Administrative Act, except in limited cases of emergency rulemaking, to provide the public with an opportunity to review, consider, and comment on draft regulations before they are finalized. Upon release of the proposed rule, opponents instantly began to express concerns that it will reduce the obligation of academic institutions to investigate complaints of sexual misconduct and decrease the likelihood that they will respond to the issue of sexual misconduct seriously. Another objection is that unlike previous federal policy, institutions would be responsible only for investigating misconduct that occurred within programs sanctioned by a college, thereby reducing protections for students assaulted or harassed off-campus. Equally contentious is a provision that would require colleges to allow for cross-examination of students in campus proceedings, but not allow the parties themselves to interact. Once published in the Federal Register, the rule enters a 60-day public notice and comment period.

Allowing The Department Of Education And The Internal Revenue Service To Share Student Data
An example of bipartisanship on display in the Senate following the recent election was the introduction of S. 3611 on November 13, 2018 to amend the Internal Revenue Code of 1986 and the Higher Education Act of 1965 to facilitate the disclosure of tax return information to carry out the 1965 Act, and for other purposes. The bill, co-sponsored by Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) of the Committee on Health, Education Labor & Pensions (HELP), is cited as the Faster Access to Federal Student Aid (FAFSA) Act of 2018. This proposed legislation would amend the Internal Revenue Code, which currently prohibits the IRS from sharing taxpayer data with the Department of Education, to allow the IRS to disclose tax return information to department officials "determining eligibility for, and amount of, Federal student financial aid."

Reauthorization Of The Higher Education Act (HEA)
The takeover of the House of Representatives by Democrats can be expected to reduce the likelihood of having a Republican version of HEA reauthorization, the Promoting Real Opportunity, Success, And Prosperity Through Education Reform (PROSPER) Act (H.R. 4508), become law. That proposed legislation has attracted wide criticism by higher education lobbying groups, along with various student and veteran organizations. Instead, it is likely that Democrats will strive to have their version, the Aim Higher Act (H.R. 6543), become the basis for reauthorizing the HEA. if an when that opportunity arises.

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HEALTH REFORM DEVELOPMENTS

John Colbert

November 26, 2018

Trends Archives

The ability to access high quality health care services is a necessary, but not sufficient means of improving the health status of individuals. Race, ethnicity, health literacy, nutritious dietary patterns, being physically fit, the opportunity to live in safe neighborhoods, and the availability of jobs that provide a satisfactory level of income are among the many key factors that have an impact on health. Government programs, such as Medicare have strict limits defined statutorily that determine the scope of services that can be offered to beneficiaries. As discussed below, a recent speech on November 14, 2018 at the Hatch Foundation for Civility and Solutions in Washington, DC by Alex Azar, Secretary of the Department of Health and Human Services (HHS), provides a possible way of expanding services to include a greater emphasis on addressing social determinants of health.

Also, not only do technology developments play a major role in contributing to a constant rate of growth in the cost of health care, they complement efforts to enhance service quality. Telehealth, artificial intelligence (AI), and machine learning are key items as described below.

Addressing Social Determinants Of Health In The U.S. Through Medicare Advantage
HHS Secretary Alex Azar on November 14 stated that the department he oversees is logically positioned to think of healthcare as broad and interconnected with other needs. "Social determinants would be important to HHS even if all we did was healthcare services, but at HHS, we cover health and human services, all under one roof. In our very name and structure, we are set up to think about all the needs of vulnerable Americans, not just their healthcare needs. But what if we went beyond connections and referrals? What if we provided solutions for the whole person, including addressing housing, nutrition and other social needs? What if we gave organizations more flexibility so they could pay a beneficiary’s rent if they were in unstable housing, or make sure that a diabetic had access to, and could afford, nutritious food?” One of the best ways to do so is through Medicare Advantage, which is Part C of the Medicare program. Beginning next year, plans under Part C will be allowed to pay for a wider array of health-related benefits, such as transportation and home health visits.

Telemedicine Usage Increases In Medicare
A report sent to Congress on November 16, 2018 by the Centers for Medicare & Medicaid Services (CMS) describes an increase in telemedicine usage of about 50% in fee-for-service Medicare from 2014 to 2016. Telehealth is emerging as a tool with the potential to improve access to care, potentially reduce costs, and enhance patient satisfaction. Medicare and other telehealth services are being used currently for a range of services in rural communities, allowing patients to connect directly with health care providers and support these providers with clinical decision-making. Moreover, telestroke services connect neurologists to rural patients and providers to provide remote diagnoses and treatment recommendations. Research indicates that telepsychiatry can reduce disparities in access to psychiatric care. When delivered remotely, psychiatric care increases the chances that individuals living in rural communities will be able to access professionals who are culturally and linguistically competent.

Bioethics Influence On Artificial Intelligence and Machine Learning
According to an essay in the September/October 2018 issue of The Hastings Center Report, artificial intelligence (AI) and machine learning have the potential to revolutionize the delivery of health care. AI systems generate conclusions by applying complex algorithms to enormous data sets by replacing human reasoning with rote‐like analysis. Machine learning “trains” or “teaches” the algorithm so that it can “learn” and eventually perform its given tasks automatically. Empirical research has demonstrated that the latest generation of AI and machine learning applications not only can identity at‐risk patients, but even achieve better diagnostic performance than expert physicians can. An example of why it is important to develop ethical frameworks that can support novel technologies has to do with the possibility that schizophrenia is over diagnosed in black patients. For a decision model to make correct predictions about the diagnosis or prognosis of these individuals seeking mental health care, factors such as their social history, their access to providers or hospitals, and the quality of hospitals available to this patient population play an important role. If a machine learning‐based decision support system continually is exposed to this ailment in black patients without appropriate context, then the algorithm will wrongly “teach” the decision system that schizophrenia is common in these patients.

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ELECTION RESULTS TO PONDER

John Colbert

November 26, 2018

Trends Archives

Elections that occur in the middle of a presidential term may provide useful insights regarding directions in which voters prefer to have some corrective measures implemented. Typically, the party that occupies the White House experiences mid-term losses in both congressional and state contests. The year 2018 was no exception insofar as Democrats in Congress regained having a majority in the House of Representatives. Much of what they may hope to achieve will be tempered to a certain extent, however, by the fact that not only will Republicans maintain control of the Senate for the next two years, they will do so with more members than they had prior to the election.

Health was the number one issue for many individuals casting ballots throughout the U.S. Democrats running for office campaigned on promises to protect key provisions of the Affordable Care Act, such as defending protections for patients with pre-existing conditions and preventing future Republican efforts to repeal the ACA. Members of the G.O.P emphasized the risk of heightened fiscal dangers that will occur if either Medicare for All legislation or any single-payer health insurance variation aimed at making health care available at little or no cost for patients ever is enacted.

One policy area of concern may lend itself to some bipartisan agreement. Key members of the Democratic party and President Trump have expressed interest in curbing pharmaceutical price increases. Generally, Republicans tend to oppose government action to set or influence prices. Yet, it would come as no surprise if House Democrats try to require direct government negotiation of Medicare Part D drug reimbursement policy. Democrats also can be expected to be more aggressive when it comes to investigating drug manufacturers suspected of being responsible for initiating price increases of their products. The pharmaceutical industry may not be alone, however, in attracting greater congressional scrutiny. An example involves what is called “surprise bills” that may arise unexpectedly after patients are discharged from hospitals. This issue also has some potential to attract bipartisan support in search of a remedy.

Marijuana legislation usually generates more attention at the state rather than the federal level, but the topic remains of interest to Democrats on Capitol Hill. Republican Pete Sessions of Texas was defeated earlier this month after serving as Chairman of the important House Rules Committee. While in that position, he was able to block proposals from being considered on the House floor, such as allowing states to develop their own approaches to marijuana regulation. His departure may signal increased efforts in that chamber to advance marijuana policy reform measures.

Apart from what occurs in Washington, DC significant actions will continue to occur at the state level. Michigan will move forward in legalizing adult recreational marijuana use, while a medical marijuana ballot measure was approved in Missouri. Voters in Idaho, Nebraska, and Utah approved ballot referenda to expand their Medicaid program coverage under the Affordable Care Act. Newly elected governors in Kansas, Maine, and Wisconsin can be expected to take action to expand their respective Medicaid programs.

Meanwhile, whatever unfolds in the coming two years will serve as an important prelude to identifying key debatable propositions that will manifest themselves in the next election scheduled for 2020.

return to trends november 2018

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

John Colbert

November 26, 2018

Trends Archives

By Susan N. Hanrahan, ASAHP President

I am not sure we had a spring or fall in the Mid-South because we went from winter to summer and now have gone from summer to winter. Climate change has seemed to eliminate two of my favorite seasons. Good grief!

Want to thank everyone who attended our Annual Conference in St Pete. We had some great speakers (plenary, poster and platform), beautiful venue (despite the high humidity during the storm) and good celebrations. Our evaluation feedback supported that. We were also given some ideas for our Charleston conference next year (Oct 16 -18) and planning has already begun.

A couple of things I want to share. We are working to enhance our website so that information on committees and task forces is more robust and that links to our Regional Deans groups are available. Even though the deans groups are not “officially” part of ASAHP, they are an avenue for deans across the US to get together outside of our annual conference to discuss and brainstorm on items of mutual interest.

Our International Task Force has completed some preliminary work in better understanding the need for health workers (predominately rehab) internationally and a desire for education and certification for those individuals. Originally it seemed that a “country by country” approach would be needed but the committee has opted for an ‘economies of scale’ model. We have put together a small group to establish the process for standard setting and to use this conceptual framework to develop a set of standards that defines the expected competencies of a rehab health worker.

Once complete, they can be sent globally for peer review. Individual countries can choose to adopt these standards for certification of their rehab health workers. That will be part one. We are partnering, and have entered into a non-disclosure agreement, with the Commission on Graduates of Foreign Nursing Schools (CGFNS) who knows all about process. Rich Oliver (ASAHP) and Julia Dutka (CGFNS) will be co-chairing the group along with ASAHP members Fevzi Akinci, Duquesne University, Katherine Beissner, SUNY Upstate, and David Henzi, UT San Antonio. This is a substantive first step.

One of our most valued assets in the Association is the Journal of Allied Health. We have formed a task force led by Greg Frazer, University of South Alabama, with members Jon Williamson, UT Southwestern, and Bonnie Van Lunen, Old Dominion University, to look at the journal itself for new opportunities while keeping in the back of their minds, succession planning. Our current Editor, Tom Elwood, has been so vital to our operations for so many years. We rely on him heavily and often forget about doing specific planning around the journal itself. If you have thoughts about the journal, please share those with Greg or myself.

Lastly, the Board has selected Phyllis King, University of Wisconsin, Milwaukee as its President-Elect for 2019. Phyllis most recently led the Leadership Development Program for ASAHP, currently serves on the Board of Directors and has been an active member of ASAHP for many years. I look forward to my continued work with Phyllis. Many more things to share but please know that if you have ideas about the Association or want us to put you to work, let me know at hanrahan@astate.edu. Happy ALL holidays between now and next year!!!

Susan Hanrahan, President

Return to November 2018 trends

HEALTH SILO DISRUPTION AND ERADICATION

John Colbert

November 26, 2018

Trends Archives

A lamentation expressed over the decades is that the health domain is dysfunctional to some degree because of the existence of silos that separate clinical services and the health professionals who provide them. One example will suffice to illustrate the nature of the problem. A patient can be referred to a practitioner in a different profession. That visit will be characterized by having to devote 10-15 minutes filling out a form on paper to register information about current medications in use, recent hospitalization episodes, allergies, and family history of particular diseases. A physical examination and the administration of some laboratory-based tests may follow, but there is no guarantee that any of this critical information subsequently will reach all relevant providers furnishing care for that patient.

A lack of interoperability is a dominant concern. Although efforts are underway to share information, no effective mechanism exists to establish a repository to house clinical data and ensure that it properly can be distributed to health professionals involved in patient care. Thus, it should be evident that efforts are necessary to make improvements that can occur on both an intramural and an extramural basis.

From an Intramural perspective, advances have been made through initiatives in interprofessional education to enable students from different health professions to learn about the unique contributions that personnel from other fields contribute to the betterment of both individual and population health status. Depending on the kind of employment undertaken upon completion of academic preparation, it is inevitable that some jobs will entail a mix of practitioners from a broad spectrum of disciplines. For instance, a neonatal intensive care unit (NICU) may provide care for an infant with a gestational age of 22-24 weeks who weighs only one pound. Cardiology, nursing, respiratory therapy, nutrition, and physical therapy are among the professions involved whose representatives must work together in a seamless manner to provide the most effective team-oriented care required.

The Extramural sphere is a region where health professionals stand to benefit from research and discoveries that emerge from totally different fields. For example, investigators in polymer chemistry and macromolecular science and engineering are studying the use of bio-inspired materials to develop products that mimic the adaptable skin of a sea cucumber for potential use in creating a worm-like robot to deliver a stent or remove plaque by crawling through a blood vessel.

Actuarial science personnel are using predictive analytics to figure out how to employ big data to direct patients to higher quality, lower cost providers. Computer scientists at Sandia National Laboratories are working to improve this nation’s biosurveillance system that alerts authorities to disease outbreaks by mimicking the human immune system. The November 2018 issue of the International Journal of Molecular Sciences discusses how the marine environment creates opportunities for acquiring new substances with anti-cancer activity. Overall, perhaps an unlimited number of resources are in a position to be exploited, but only if health professionals are willing to embrace the challenge of attempting to disrupt and eradicate the artificial boundaries that separate a vast multiplicity of disciplines.

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IDENTIFICATION OF FITNESS TRENDS FOR 2019

John Colbert

October 29, 2018

Trends Archives

While much of the health care domain is characterized by efforts to treat disease, an important portion of it is oriented toward enhancing health promotion and disease prevention. The November 2019 issue of the American College of Sports Medicine’s (ACSM's) Health & Fitness Journal features articles and columns dedicated to several top trends in the 2019 fitness survey, a study in its 13th consecutive year of being conducted. Responses came from more than 2,000 health fitness professionals from around the world and these respondents represented all sectors of the industry: commercial, clinical, community, and corporate. This annual survey is viewed as being useful because it emphasizes the value of appreciating the differences between trends and fads in the fitness industry, helping to make important investment decisions and programming decisions for future growth and development. Despite the inherent difficulty of predicting the future of any industry, the survey helps to track trends that can assist owners, operators, program directors, and health fitness professionals with making important business decisions.

Wearable technology took over the #1 spot for 2019 after dropping to #3 in 2018, which may be the result of manufacturers correcting some monitoring inaccuracies of the past. High Intensity Interval Training (HIIT), the #1 trend in 2014 and 2018, fell to #3 for 2019. Group training made a significant return in 2017 as the #6 trend and has been the #2 trend for the past two years (2018 and 2019). Fitness programs aimed at older adults have regained some popularity after falling out of the top 10 trends in 2017, appearing at #9 in 2018 and becoming #4 for 2019. Bodyweight training first appeared as a fitness trend at #3 in 2013 and has been a top five fitness trend since that time, realizing a peak as the #1 fitness trend in 2015. In 2019, bodyweight training is the #5 fitness trend. A new trend to watch will be the employment of certified fitness professionals, a new potential trend for 2019 (#6) replacing educated, certified, and experienced fitness professionals, which was determined to be too broadly defined for this survey. Other trends to watch are mobile exercise apps, worksite health promotion and workplace well-being programs, outcome measurements, and post-rehabilitation classes.

Return to October 2018 trends

GENDER PEER EFFECTS IN DOCTORAL STEM PROGRAMS

John Colbert

October 29, 2018

Trends Archives

The underrepresentation of women in science, technology, engineering, and mathematics (STEM) fields can begin as early as grade school and intensify at each successive career step so that men greatly outnumber women as scientists and engineers at senior levels. This underrepresentation of women in STEM is a topic of great interest in economics and public policy today. Yet, factors affecting persistence in these fields are not well understood and understanding the nature of the situation especially is limited at the graduate education level. A step in the direction of learning more is represented by a paper released by the National Bureau of Economic Research (NBER) last month. It describes an investigation of peer gender composition in the training process of STEM doctoral degrees.

Using year-to-year variation within doctoral programs in the fraction of each cohort that is female, researchers found that women in cohorts with no female peers are less likely to graduate within six years of initial enrollment than men, but an increase in the share of female peers in a cohort increases the probability of on-time graduation for women as compared to their male counterparts. This effect largely is driven by students in typically male programs (less than 38.5% female students in the average cohort) and by dropout behavior in the first year of enrollment. Peer gender composition has a small effect on first term GPA and no effect on the probability of obtaining research funding. The small/null findings for these two channels suggest that the results largely cannot be explained by women learning or competing more successfully in cohorts with more female peers. The findings are consistent, however, with a climate mechanism, through which more female peers create a female friendly environment that encourages women to persist in doctoral programs, despite having no significant effect on learning or financial support. Taken together, the findings indicate that peer gender composition can be a useful proxy for climate and that yearly variations in this measure can provide a useful identification strategy for investigating gender gaps in outcomes.

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AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

John Colbert

October 29, 2018

Trends Archives

2017 National Healthcare Quality And Disparities Report
For the 15th year in a row, the Agency for Healthcare Research and Quality (AHRQ) has reported on progress and opportunities for improving healthcare quality and reducing healthcare disparities. The 2017 National Healthcare Quality and Disparities Report recently was made available. It tracks more than 300 healthcare process, outcome, and access measures, covering a wide variety of conditions and settings. The report and chartbooks are organized around the concept of access to care, quality of care, disparities in care, and six priority areas, including patient safety, person-centered care, care coordination, effective treatment, healthy living, and care affordability. Trends show that about 55% percent of quality measures are improving overall for Blacks, however, most recent data in 2014-2015 show that about 40% of quality measures were worse for Blacks compared with Whites. Trends also show that about 60% of quality measures are improving overall for Hispanics, but in 2014-2015, nearly one-third of quality measures were worse for Hispanics compared with non-Hispanic Whites. The report can be obtained here.

Interoperability Among Health Care Technologies
While health care has made great strides in the proliferation of electronic health records, establishment of regional health information exchanges, and development of data exchange standards and interfaces, interoperability among health care technologies remains quite limited, according to a report from the National Academy of Medicine that recently was made available. Interoperability is the ability to deliver data seamlessly and automatically across time and space from and to multiple devices and organizations. A lack of interoperability results in waste, inefficiency, and clinician burnout, according to the report. The document outlines steps for health systems to establish comprehensive, ongoing procurement strategies with system-wide interoperability by moving away from serial purchases of individual software and hardware with proprietary interfaces toward those that will interoperate with others through a vendor-neutral open platform. The report also contains a technical supplement that details specific approaches. It can be obtained here.

Enhancing High Schools As A Driver Of Individual Mobility And Community Progress
For much of the last century, high schools served as a driver of individual mobility and community progress. Today, however, in too many school districts and communities, high schools are no longer fulfilling that promise. There remain about 1,300 traditional high schools in need of serious improvement and redesign. With an average graduation rate of 49%, these low-graduation-rate high schools are concentrated in 18 states from the inner city to the heartland and sit at the fault lines of race, class, and inequity in America. Yet, clear rays of hope exist. Over the last two decades, the number of low-performing high schools has been cut in half, as high school graduation rates have reached an all-time high. While graduation at the remaining low-performing high schools still is just a 50-50 proposition, these schools make up a small percentage of high schools throughout the country, totaling just 10% of all traditional high schools enrolling 300 or more students. Among its various topics, the Great American High School report includes coverage of progress made and remaining challenges in enabling all students to graduate from high school ready for college or career. The report can be obtained here.

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

John Colbert

October 29, 2018

Trends Archives

U.S. Adults Who Should Take Statins For Heart Disease Prevention Fail To Do So
Only 42% of the 26.8 million adults for whom statins are recommended to prevent heart disease actually take the medications, according to an Agency for Healthcare Research and Quality (AHRQ) study. Statin use rates have remained flat in the last decade, despite evidence that they reduce death from heart disease. In 2016, the U.S. Preventive Services Task Force (USPSTF) released new recommendations on statin use to prevent heart disease, the leading cause of death among adults age 40 and older. Using data from AHRQ’s Medical Expenditure Panel Survey to assess the size and characteristics of the population that meets the USPSTF criteria for statin use, researchers found that among adults recommended for statin use, women, Hispanics and individuals living in the South or without health insurance were less likely to receive them. A conclusion reached is that new USPSTF recommendations may result in decreased personal costs and expanded access to statins.

Fast Food Consumption By U.S. Adults
Data from the National Health and Nutrition Examination Survey reveal that during 2013–2016, 36.6% of adults consumed fast food on a given day. The percentage decreased with age: 44.9% aged 20–39, 37.7% aged 40–59, and 24.1% aged 60 and over. A higher percentage of non-Hispanic black adults consumed fast food than non-Hispanic white, non-Hispanic Asian, and Hispanic adults. The percentage of adults who consumed fast food increased with more family income. Among those who consumed fast food, men were more likely than women to eat fast food at lunch, but women were more likely to report eating fast food as a snack. Fast food is a part of the American diet and has been associated with high caloric intake, and poor diet quality. Time, financial resources, price, and availability influence fast food consumption, which was based on 24-hour recall.

HEALTH TECHNOLOGY CORNER

Use Of Biological Swimmers As Cargo Delivery Agents In Blood
Nature presents intriguing biological swimmers with innate energy harvesting abilities from their local environments. Use of natural swimmers as cargo delivery agents presents an alternative strategy to transport therapeutics inside the body to locations otherwise difficult to access by traditional delivery strategies. A manuscript published on September 25, 2018 in the journal Advance Materials describes a biocompatible biohybrid microswimmer powered by a unicellular freshwater green microalga, Chlamydomonas reinhardtii. Nontoxic and biodegradable, it moves by lashing a propeller-like tail. The researchers outfitted individual algal cells with magnetic polymer beads that could hold drugs in small amounts and allowed the researchers to steer the algae by applying a magnetic field to them. In the laboratory, these microswimmers darted through bodily fluids such as blood at more than 100 micrometres per second and successfully deposited payloads onto mammalian cells.

Novel Devices For Studying Acute And Chronic Mechanical Stress In Retinal Pigment Epithelial Cells
Macular degeneration (AMD) is the leading cause of adult blindness in developed countries. Physical changes within the retina are an important factor in its development. As reported in a study published on October 8, 2018 in the journal Lab on a Chip, researchers at Utah State University aimed to mimic changes in cells and find the mechanisms for the initiation and progression of diseases. Their study examines the effects of mechanical stress on elevated protein levels and abnormal development of new blood vessels. They were able to develop new devices to stress human cells in the lab mechanically. One device is designed to mimic slow and continuous stress levels and a second one is used for mimicking high levels of stress. They discovered that mechanical stress results in the expression of vascular endothelial growth factor, a protein that can cause disease initiation and progression. Besides AMD, mechanical stress can occur in other diseases including diabetic retinopathy and even cancer.

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DEVELOPMENTS IN HIGHER EDUCATION

John Colbert

October 29, 2018

Trends Archives

Students and their families view attainment of a baccalaureate degree as an important first step in obtaining a decent paying job upon graduation. Given the fact that the costs of pursuing a college education are beyond the financial reach of many families in the United States today, they especially want their investment to produce favorable outcomes for their offspring in the job market.

Unfortunately, not all academic majors are geared toward producing graduates who will be in high demand by employers seeking workers with that level of formal education. According to a new report from the data analytics firm Burning Glass Technology, some vocationally geared majors, such as fitness studies and criminal justice do not fare as well compared to majors in other areas, such as English and gender studies. All too many students may find jobs after graduation, but in the context of their educational background, they are underemployed.

Health care education programs continue to be an exception. A rapidly growing proportion of the population that is age 65 and older, a group characterized by highly significant numbers of individuals who have one or more chronic conditions, means that the demand for health care services will grow. Shortages of physicians and dentists suggest that there will be increased opportunities for graduates of physician assistant and dental hygiene programs, to cite just two examples, to obtain gainful employment in the health sector following graduation. A challenge will be to ensure that high school graduates are prepared adequately in science and mathematics to thrive academically in health science higher education programs. Just as importantly, it will be essential to attract more students from underrepresented racial and ethnic groups in order to achieve a greater alignment with major demographic changes that the U.S. population is undergoing.

Negotiated Rulemaking For Accreditation And Innovation
The U.S. Department of Education (USDE) announced a negotiated rulemaking on higher education accreditation and innovation, along with three subcommittees to address distance learning and educational innovation, faith-based entities’ participation in Title IV programs and TEACH Grants. A main committee will focus on accreditation while three subcommittees will address these additional issues. The negotiated rulemaking committee will meet three times in 2019: on January 14-16, on February 19-22, and on March 25-28. Each of the three subcommittees also will meet three times, on January 17-18, February 12-13, and March 11-12. The meetings will be held in Washington, DC. Topics to be addressed by the main committee will include:

Requirements for accreditors in their oversight of institutions
Criteria used by the Secretary to recognize accrediting organizations
Simplification of USDE’s recognition of accrediting organizations
Clarification of the responsibilities for each member of the “triad” (accreditors, states and USDE)
Clarification of permissible arrangements between institutions and others providing an education program

Delayed Publication Of New Regulations For Borrower Defense And Gainful Employment
The USDE also announced that final regulations for borrower defense to repayment will not be published by November 1, 2018. The agency received more than 38,000 comments on its proposed borrower defense rules, indicating that additional time is needed to review the comments. Borrower defense regulations focus on the conditions under which students may obtain relief from federal loans. Additionally, final gainful employment regulations also will not be published by November 1, which means that current gainful employment regulations will remain in effect. These regulations address whether or not students who have borrowed federal money complete programs leading to earnings that enable the students to repay the loans. The missed deadlines for publishing new borrower defense and gainful employment regulations mean that the earliest date either could be implemented will be July 2020.

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PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

John Colbert

October 29, 2018

Trends Archives

By Susan N. Hanrahan, ASAHP President

In my message in the November 2017 issue, I indicated that I will be asking some of you to send a photo and answer a series of “fun” questions to be shared with our membership so that we can continue our collegiality through our newsletter. The 6th of many profiles this year is presented as follows:

Name and Title: Patricia A. Prelock, Ph.D., CCC-SLP, BCS-CL, Professor & Dean, College of Nursing and Health Sciences

Place of birth: Youngstown, OH

University: University of Vermont, Burlington, VT

How long have you been in your position? I am in my 10th year as Dean for the College of Nursing and Health Sciences and I have been a Professor in Communication Sciences and Disorders and in Pediatrics in the Larner College of Medicine for 18 years.

What’s the value of a university education? A university education creates opportunities for our next generation of scholars, leaders and health care professionals to create new knowledge, challenge perspectives, think critically, problem solve, and facilitate innovations in teaching, learning and practice.

What is the value of ASAHP? As a very new member of the organization, our college is experiencing the value of the communications (journal and updates), the opportunities for leadership training, and the potential for networking. We are just getting our feet wet in this new circle of connection with shared values and goals.

If I could teach in another field, which one and why? As a true interdisciplinary professional, I love teaching across the disciplines of medicine, social work, PT, nutrition, nursing, OT, education, psychology, integrative health, early childhood and special education. If I had to select one, it would probably be medicine (e.g., pediatrics, psychiatry, neurology) as I think they would gain significant value in understanding the roles and responsibilities of other health related disciplines.

Before I retire I want to: I don’t have any plans to retire as I love what I do, although I may slow down a bit in the next 10 years.

In college, I was known for: My energy and passion for serving with meaning.

What music is playing in my car/office? Typically, you would hear classical or country-western music. The last book I read for fun was: Throwaway Children by Diney Costeloe

My favorite trip was: A Mediterranean cruise with my husband Billy during which we visited London, Italy, Spain, France, and the Rock of Gibraltar. I have enjoyed, however, several recent professional trips to Hong Kong, Japan, and China.

My hobby is: Walking, boating, snowshoeing, magic, traveling.

My passion is: My grandchildren and serving the needs of children with autism spectrum disorders.

Cats or dogs? We have 2 dogs, Riley (1 year old German Shepherd) and Cocoa (9 year old chocolate lab & a therapy dog).

E-book or hardback? I love the feel and ability to leaf through the pages of a hardback book.

Beach or mountains? We live on a sandy beach on Lake Champlain and can see both the Green Mountains of Vermont and the Adirondacks of NY, so I love the beach, the mountains and the trees of Vermont.

Return to TRENDS October 2018

REFLECTIONS ON AN EXPERIMENT IN DEMOCRACY

John Colbert

October 29, 2018

Trends Archives

The founders of this nation envisioned an arrangement in which the executive, legislative, and judicial branches of government would function effectively to meet the needs of the populace in both domestic and foreign matters. That experiment has endured for some 240 years in times both good and bad. Leaders in all three branches either are elected or appointed while the month of October in each even-numbered year results in a federal election that involves one-third of the Senate and all members of the House of Representatives who aspire to remain in office. These officials return home that month to make their individual appeals to the electorate.

Much of what transpires in government that works beneficially tends to occur without attracting much notice. Social Security checks are mailed or deposited into private accounts every month, payments are made to providers by the Centers for Medicare & Medicaid Services, and members of the military serve in posts throughout the world to safeguard the nation’s interests. As of the end of October 2018, the U.S. Census Bureau estimates that the population is nearly 329 million inhabitants. Given that a typical family consisting of only five individuals can engage in heated disputes regarding, what time to have dinner, what to eat, and whether the meal should consist of home-cooked or carry-out comestibles, it comes as no surprise that a national agglomeration in the hundreds of millions will generate vastly different and especially noisy opinions on the essential roles that government should play in their lives.

Key political factions often are described in binary terms, such as Democrat and Republican or liberal and conservative. Stuck in heavy traffic with no idea of what is happening further up the road and well beyond view, a liberal might conclude that if a police officer was at the main intersection that lies in the distance, traffic would be able to flow more smoothly. A conservative sitting in the next vehicle might just as easily believe that there must be a uniformed official at that same intersection. Otherwise, the situation would not be as messed up as it appears to be. The basic difference between these opposing points of view is that one group believes that government must be more involved as a desirable mechanism to solve various problems while the other group sees that same entity as the cause of a great many difficulties.

Yet, although progress may appear to be too slow at times, constructive action does occur. Presidents propose budgets and Congress acts on them in ways that its members see fit. Ultimately, agreements are reached on spending priorities and the chief executive signs appropriation bills into law. Medicare data show that spending for this program was 15 percent of total federal spending in 2016 and is projected to rise to 17.5 percent by 2027 while the Medicaid program helped provide health care to an estimated 73 million individuals in fiscal 2017 at a cost of about $596 billion. Several congressional committees and sub-committees in both chambers provide valuable oversight of executive branch activities pertaining to these two programs. Moreover, public hearings furnish an opportunity for representatives of a wide range of organizations in the private sector to weigh in with their opinions in ways that accrue to the advantage of program beneficiaries.

As was the case with deciding on the legality of the individual mandate created by the Affordable Care Act, the Supreme Court also sometimes will join a fray to arbitrate jurisdictional controversies. Thus, while it is somewhat less than perfect, the nation’s experiment in democracy endures in meaningful ways.

return to trends october 2018

More Articles from TRENDS December 2018 - January 2019

CALLING UNCLE SAM AND ALEXA

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

FEDERAL BUDGET AND THE OPERA

DEVELOPMENTS IN HIGHER EDUCATION

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

DETECTING BS IN HEALTH CARE

PHYSICAL THERAPY AND OCCUPATIONAL THERAPY GUIDELINES

More Articles from TRENDS December 2018 - January 2019

CALLING UNCLE SAM AND ALEXA

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS