January 20, 2021

HEALTH REFORM DEVELOPMENTS

January 20, 2021

During the Obama and Trump Administrations, the Patient Protection and Affordable Care Act of 2010 has been a centerpiece of health policy initiatives. The U.S. Supreme Court played a decisive role in 2012 by ruling that the law would remain in effect despite an attempt by Republicans to eliminate it over a provision involving an individual mandate that originally was intended as a penalty to be imposed on individuals who decided not to seek insurance coverage. The high court ruled that if the mandate was considered a tax instead of a penalty, then the law would remain intact. When Congress eliminated the tax in 2017 in overall legislation signed into law by President Trump, Republican Attorneys General around the nation argued in federal court that ending the tax provided a rationale for scuttling the entire Affordable Care Act (ACA), which no longer can be considered constitutional. The Supreme Court accepted the case and a ruling is expected to be issued later this year.

Meanwhile, total national healthcare spending in 2019 grew 4.6%, which was similar to the 4.7% growth in 2018 and the average annual growth since 2016 of 4.5%, according to a new analysis conducted by the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS). The share of the economy devoted to health spending was relatively stable in 2019, at 17.7% compared with a 17.6% share in 2018. The 4.6% growth in health care expenditures was faster than the 4.0% overall economic growth as measured by Gross Domestic Product (GDP) in 2019. The growth in total national healthcare expenditures in 2019 reached $3.8 trillion, or $11,582 per person, up from 2018 when total national health expenditures were $3.6 trillion, or $11,129 per person. Spending for personal health care, which includes health care goods and services, accounted for 84% of total health care spending in 2019 and increased 5.2%, a faster rate than the 4.1% it increased in 2018. The faster growth in personal health care spending was driven largely by growth for hospital care, retail prescription drugs, and physician, and clinical services. The report includes health expenditure data though 2019, but not any of the effects of the coronavirus disease 2019 (COVID-19) pandemic on health care spending.

Undoing Trump Administration Health Policies

A common practice whenever a new administration led by one political party replaces an administration of the other political party in the nation’s capital is to undo policies implemented by the predecessor group. For example, one Trump administration regulatory initiative created 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 such 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. Other high profile policies that democrats found to be objectionable involved the joint federal-state Medicaid program. Examples are demonstration projects that allow work requirements and block granting of federal Medicaid funds.

Mechanisms Likely To Be Used By The Biden Administration To Reverse Trump Policies

A 50-50 split between democrats and republicans in the Senate means that tie votes can be broken by Vice President Kamala Harris. With democrats in control of the House and a fellow party member occupying the White House, legislative objectives can be achievable through the enactment of laws. A related approach would be to use budget reconciliation procedures to pass some tax and spending measures in areas, such as ACA enhancement, pandemic relief, and climate change. The process begins with a budget resolution. Next, reconciliation legislation is then considered using a fast-track process that can be passed by a simple majority without having to be filibustered in the Senate. Limitations exist since budget reconciliation cannot be used for any and all federal legislation. Instead, bills must contain provisions that affect revenue and spending, with no extraneous items allowed, according to a restriction known as the “Byrd Rule.” Named after its principal sponsor, Senator Robert C. Byrd, D-WV), the rule provides six definitions of what constitutes extraneous matter. The Byrd rule has been in effect during Senate consideration of 21 reconciliation measures from late 1985 through the present.

return to December 2020 - January 2021 trends

More December 2020 - January 2021 TRENDS Articles

SIR ISAAC AND THE WHOLE BIRD

Discusses political polarization and new opportunities to produce bipartisan solutions for physical and mental health problems. Read More

117TH CONGRESS IS UNDERWAY

looks at some major appropriations that were enacted for fiscal year 2021. Read More

HEALTH REFORM DEVELOPMENTS

points out how the incoming Biden administration may undo certain policies of the previous administration and indicates some mechanisms for doing so. Read More

DEVELOPMENTS IN HIGHER EDUCATION

lists some funding made available by the enactment of the Consolidated Appropriations Act, 2021 and also refers to additional financial assistance provided in a separate coronavirus-relief package. Read More

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

COVID-19 Trends Among Individuals Aged 0-24 Years, United States
Alcohol Consumption, Cardiac Biomarkers, And Risk Of Atrial Fibrillation
Targeting Cartilage EGER Pathway For Osteoarthritis Treatment
Infection Trains The Host For Microbiota-Enhanced Resistance To Pathogens Read More

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

When Back To School Meets Stay At Home
Equity-Minded Faculty Workloads: What Can And Should Be Done Now
2021 Federal Health Insurance Exchange Weekly Enrollment Read More

PERSONAL RESPONSIBILITY AND SOCIAL DETERMINANTS

Examines the issue of how personal behavior and social determinants interact to influence health status. Read More

GENTRIFICATION IMPACTS ON HEALTH

Pertains to a discussion regarding whether the gentrification of urban neighborhoods is a net benefit or is harmful. Read More

Kristen Truong

January 20, 2021

117th CONGRESS IS UNDERWAY

Kristen Truong

January 20, 2021

The early days of the opening of the first session of the 117th Congress began in an unprecedented manner. As legislators in both chambers gathered to certify electoral votes cast in the 2020 election, a mob assaulted the U.S. Capitol on January 6, inflicting a major disruption of the proceedings. Once order was restored, officials were able to continue later that same evening to take action they had begun to perform earlier that day. Just as dramatically, almost immediately thereafter, voices emphatically called for removing President Trump from office at once for what was perceived as his role in inciting the building’s marauders. Steps rapidly were initiated that resulted in an effort to impeach him for the second time in only 13 months.

Prior to the start of the new session of Congress, its immediate predecessor 116th version was characterized by an agreement reached in late December 2020 to provide funding to prevent a federal government shutdown. President Trump signed into law the Consolidation Appropriations Act, 2021 (P.L. 116-260) on the 27th of that month to appropriate more than $1.4 trillion for fiscal year 2021, along with the inclusion of $900 billion for pandemic relief that involves funding for vaccine distribution and COVID-19 testing. This legislation cleared the U.S. House of Representatives and Senate on a bipartisan basis one week beforehand. A 2,124-page bill, it covers an extensive range of programs, including many that pertain to the health sphere. Some examples of what the agreement provides are as follows:

$42,934,000,000 for the National Institutes of Health, including $404,000,000 from the 21st Century Cures Act (Public Law 114-255), an increase of $1,250,000,000, or 3%, above fiscal year 2020. The agreement provides a funding increase of no less than 1.5% above fiscal year 2020 to every Institute and Center (IC).

$7,874,804,000 in total program level funding for the Centers for Disease Control and Prevention, which includes $6,963,296,000 in budget authority and $856,150,000 in transfers from the Prevention and Public Health (PPH) Fund.

$338,000,000 for the Agency for Healthcare Research and Quality.

$2,000,000 increase for a total of $43.3 million for Area Health Education Centers for new competitive grants to expand experiential learning opportunities through simulation labs designed to educate and train healthcare professionals serving rural, medically underserved communities, that shall include as an allowable use the purchase of simulation training equipment.

As the result of an election in Georgia on January 5, two Democrats won contests for the U.S. Senate, so that beginning on Inauguration Day, Vice President Kamala Harris will be able to exert a tie breaking vote in that chamber, which means that Democrats will be in control of both Congress and the White House. It can be expected that they will use this opportunity to fulfill their legislative objectives.

return to December 2020 - January 2021 trends

SIR ISAAC AND THE WHOLE BIRD

Kristen Truong

January 20, 2021

Sir Isaac Newton in 1686 presented his three laws of motion in the Principia Mathematica Philosophiae Naturalis. His first law states that “Every object persists in its state of rest or uniform motion in a straight line unless it is compelled to change that state by forces impressed on it.” A cursory review of the print and broadcast media in the U.S. indicates that a considerable amount of polarization exists in how the performance of U.S. presidential administrations is evaluated. As Trump bureaucrats exit stage right on January 20, certain media punditi can be expected to continue to extol perceived legislative and regulatory accomplishments by his executive team, which also happened to be roundly derided by opponents. Meanwhile, with the entrance of the Biden Administration stage left, it is likely that his supporters in the media will provide high encomia for whatever policies unfold while detractors on the other side of the ideological divide will continue steadfastly to circulate views that are somewhat less than totally enthusiastic.

This form of polarization often is characterized by the political terms right wing and left wing. Given the many challenges facing this nation, however, perhaps it is not unreasonable to hope for the emergence of bipartisan solutions that reflect the whole bird instead of its dual avian appendages. For example, the spheres of physical and mental health at both individual and community levels represent areas that are ripe for seeking meaningful bipartisan consideration. To illustrate, a manuscript published in the issue of the journal Neuropsychopharmacology in January 2021 describes the “Adolescent Brain Cognitive Development (ABCD)” study, an investigation currently underway to obtain a better understanding of the development of healthy and disrupted brain and behavioral development.

This research is the largest in the U.S. to date assessing brain development, examining youth from age 9 to 10 for approximately 10 years into young adulthood. Its dataset has a wealth of measured attributes of youths and their environment, including neuroimaging, cognitive, biospecimen, behavioral, youth self-report and parent self-report metrics, and environmental measures. Initial driving questions of the ABCD Study included examination of risk and resiliency factors associated with the development of substance use. The effort since then has expanded beyond this early set of questions by greatly informing an understanding of the contributions of biospecimen-derived (e.g., pubertal hormones, genomic, and epigenetic factors), neural, and environmental factors to the etiology of mental and physical outcomes from middle childhood through early adulthood.

The arrival of the coronavirus in 2020 and subsequent mutations of this disease that have evolved offer compelling evidence once again beyond a shadow of any doubt that while driving through life, humans cannot always count on being in full control at the wheel. National and international attention on the importance of health issues are galvanizing factors that emphasize the importance of focusing on crafting bipartisan solutions for pressing mental and physical health problems. A new Administration in the nation’s capital has a superb opportunity to show that it will rise to the occasion of meeting many key challenges that must be addressed.

return to December 2020 - January 2021

More December 2020 - January 2021 TRENDS Articles

SIR ISAAC AND THE WHOLE BIRD

Discusses political polarization and new opportunities to produce bipartisan solutions for physical and mental health problems. Read More

117TH CONGRESS IS UNDERWAY

looks at some major appropriations that were enacted for fiscal year 2021. Read More

HEALTH REFORM DEVELOPMENTS

points out how the incoming Biden administration may undo certain policies of the previous administration and indicates some mechanisms for doing so. Read More

DEVELOPMENTS IN HIGHER EDUCATION

lists some funding made available by the enactment of the Consolidated Appropriations Act, 2021 and also refers to additional financial assistance provided in a separate coronavirus-relief package. Read More

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

COVID-19 Trends Among Individuals Aged 0-24 Years, United States
Alcohol Consumption, Cardiac Biomarkers, And Risk Of Atrial Fibrillation
Targeting Cartilage EGER Pathway For Osteoarthritis Treatment
Infection Trains The Host For Microbiota-Enhanced Resistance To Pathogens Read More

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

When Back To School Meets Stay At Home
Equity-Minded Faculty Workloads: What Can And Should Be Done Now
2021 Federal Health Insurance Exchange Weekly Enrollment Read More

PERSONAL RESPONSIBILITY AND SOCIAL DETERMINANTS

Examines the issue of how personal behavior and social determinants interact to influence health status. Read More

GENTRIFICATION IMPACTS ON HEALTH

Pertains to a discussion regarding whether the gentrification of urban neighborhoods is a net benefit or is harmful. Read More

Kristen Truong

November 23, 2020

MOVING FROM A GERM THEORY OF DISEASE TO THE MICROBIAL THEORY OF HEALTH

Kristen Truong

November 23, 2020

Owing to significant advances in microbiome science over the past two decades, a brink has been reached in a paradigm shift regarding the role of microbes in disease and health, from the Germ Theory of Disease to the Microbial Theory of Health. This shift will necessitate a change in the approaches taken to design targeted infection control. In particular, knowledge of the microbiome will need to be leveraged when attempting to reduce the risk posed by infectious agents through use of targeted hygiene, and by fostering/balancing exposure to naturally diverse microbial communities. A paper appearing in the November 2020 issue of the American Journal of Infection Control considers theories over the last 30 years that have had an impact on hygiene policy and consumer practice, from the Germ Theory of Disease and the Hygiene Hypothesis, to the Microbial Theory of Health, including the concept of Bidirectional Hygiene. A high-level review of the literature on pathogen transmission and the cycle of infection in the home and everyday settings is presented.

The authors believe it is time to restore public understanding of hygiene, and specifically targeted hygiene, as a tool for preventing transmission of pathogens (breaking the chain of infection) and, consequently, transmission of infectious diseases. Shifting the paradigm from a Germ Theory of Disease toward a Microbial Theory of Health, wellness, and disease prevention should not be allowed to undermine the critical role that targeted personal and surface hygiene practices play in interrupting the dissemination of infectious agents. Additionally, the authors indicate that it is critical to restore the public understanding of the basic principles of good hygiene practices and the importance of the concept of targeted hygiene as a means of minimizing the dissemination of infectious agents. The Microbial Theory of Health, including age-appropriate and health-appropriate hygiene practices for home and everyday life, should usher in a new era in which pathogen reduction can be accomplished without indiscriminate elimination of potentially beneficial microbes from the human and environmental microbiomes.

return to November 2020 trends

POPULATION HEALTH SCIENCE AND THE COVID-19 PANDEMIC

Kristen Truong

November 23, 2020

The first half of 2020 saw the emergence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV -2), a novel coronavirus that in a matter of weeks became a global pandemic with unparalleled consequences. It took only about three months from the time of the first diagnosis on December 31, 2019, in Wuhan, China, for the virus to be diagnosed in countries essentially all over the world. According to an article published in the November 2020 issue of the American Journal of Epidemiology, lessons are beginning to emerge that make it possible to sharpen thinking about COVID-19 by viewing it through the lens of population health science. Epidemiology lends itself to a focus on categorical outcomes, aiming to understand causes of cases. An infectious disease pandemic also lends itself naturally to categorical thinking. By contrast, a dimensional approach aims to expand that lens beyond simple case categorization, to thinking of the fuller range of health manifestation.

COVID-19 dynamics indicate that population health is best served by thinking dimensionally across a range of health indicators, expanding the focus beyond clearly defined categorical outcomes, even in the case of an infectious disease pandemic. This recognition frames how to think about the causes of the pandemic and how that might shape approaches to it. Deaths from the virus might be due to a disease that is uncurable or one that overwhelms the health system. Hence, there also should be interest in hospitalization rates and in the availability of acute care if it is needed to look after those sick with coronavirus. Economic indicators and their health consequences also should be of concern to population health, including increases in cardiovascular disease, depression, and suicide, all of which have been associated with adverse economic conditions. Even in the case of a single infection, thinking of a dichotomous outcome (being infected or not) underlies a variety of causes and outcomes that are important both for understanding the pandemic consequences and guiding what to do to mitigate these consequences.

return to November 2020 trends

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

Kristen Truong

November 23, 2020

State Of Lung Cancer In The U.S.

The third annual "State of Lung Cancer” report from the American Lung Association finds that while survival rates have improved overall, this type of cancer remains the leading cause of cancer mortality in the U.S. The report also highlights racial disparities at all stages, from diagnosis to treatment. Early diagnosis rates and surgical treatment rates are lower among Black patients and other non-white groups than white patients. At the same time, Hispanic individuals are 39% more likely to receive no treatment than white patients. Across the board, screening remains a challenge. Nearly eight million individuals were at high risk for lung cancer and ought to have been screened last year, but fewer than 6% of them ended up being screened for the disease. This year’s report examines the lifesaving potential of lung cancer screening, which can detect the disease at an earlier stage when it’s more curable, and the importance of advancements in lung cancer research that holds the promise for better treatment options. Additional information can be obtained here.

A Global Grand Challenge Of Achieving Healthy Human Longevity

The National Academy of Medicine (NAM) and global collaborators in October 2019 with the participation of 49 countries and territories launched the Healthy Longevity Global Competition to catalyze breakthrough research and generate transformative and scalable innovations by mobilizing action across disciplines and sectors, from basic research to technology, care delivery, financing, community development, and social policy. During the first phase of the competition over three years, more than 450 Catalyst Awards will be distributed globally, representing over US$30 million in seed funding to attract bold, audacious research ideas. In the second phase, “Accelerator Awards” will provide additional substantial funding or support for projects that have demonstrated proof of concept with potential for commercialization. In the third and final phase, one or more Grand Prizes totaling over US$4 million will reward breakthrough achievements with the promise of global impact. An international commission will assess the evidence and develop a comprehensive policy strategy for healthy aging. The commission’s report, to be released in mid-2021, will be informed by three workstreams: (1) social, behavioral, and environmental enablers, (2) health care and public health systems, and (3) science and technology. Information about this endeavor can be obtained here.

U.S. Maternal Death Rates Are The Highest Among Wealthy Countries

The United States has the highest maternal mortality rate among 11 high-income countries, according to a new international comparison from the Commonwealth Fund. The high rates of deaths from complications of pregnancy and childbirth reflect several factors that include an overall shortage of maternity care providers and the limited availability of postpartum care. The new study points to a number of policies that could lower maternal mortality in the U.S.

Implementing universal, comprehensive maternity care coverage and lowering barriers to accessing care.
Ensuring continuous maternity care from preconception to the postpartum period, also known as the “fourth trimester,” when the majority of maternal deaths occur.
Expanding the maternity care workforce, with a larger role for midwives, ensuring paid leave for all after giving birth.

The report can be obtained here.

return to November 2020 trends

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Kristen Truong

November 23, 2020

Chronic Pain And High-Impact Chronic Pain Among U.S. Adults, 2019

According to a Data Brief released in November 2020 by the National Center for Health Statistics (NCHS), in 2019, 20.4% of adults had chronic pain and 7.4% of adults had chronic pain that frequently limited life or work activities (referred to as high-impact chronic pain) in the past three months. Chronic pain and high-impact chronic pain both increased with age and were highest among adults aged 65 and over. Non-Hispanic white adults (23.6%) were more likely to have chronic pain compared with non-Hispanic black (19.3%), Hispanic (13.0%), and non-Hispanic Asian (6.8%) adults. The percentage of adults with chronic pain and high-impact chronic pain increased as place of residence became more rural. Chronic pain and chronic pain that frequently limits life or work activities are among the most common reasons adults seek medical care and are associated with decreased quality of life, opioid dependence, and poor mental health.

Black, Hispanic Patients Hospitalized For COVID-19 At Disproportionately High Rates

Results of a study by researchers at the Stanford University School of Medicine and Duke University published on November 17, 2020 in the journal Circulation show that Black and Hispanic patients made up nearly 60% of COVID-19 hospitalizations. This disproportionate number is attributed to societal structures reinforcing health disparities among racial and ethnic groups. The study looked at data from 7,868 patients hospitalized for COVID-19 between January 17 and July 22 at 88 U.S. hospitals participating in the American Heart Association COVID-19 Cardiovascular Disease Registry. Hispanic and Black patients had a disproportionate risk of landing in the hospital: 33% were Hispanic, 25.5% were Black, 6.3% were Asian and 35.2% were white. Data from the U.S. Census Bureau for ZIP codes where participating hospitals are located show Hispanic individuals make up just 9% of the local population, Black persons constitute 10.6%, Asian inhabitants represent 4.7%, and non-Hispanic white residents account for 59.3%.

HEALTH TECHNOLOGY CORNER

Exploration Of The The Link Between Obstructive Sleep Apnea And Autoimmune Disease

Obstructive Sleep Apnea (OSA) damages the health of 35% of adult Americans. Disordered sleep results in increased risk of several autoimmune disorders, but the molecular links to autoimmunity are poorly understood. New research by University of Georgia scientists reported in the December 2020 issue of the journal Clinical Immunology identified four cytokines associated with autoimmune disease, whose median serum levels were significantly different for OSA patients receiving airways therapy, from the levels in untreated OSA patients. Immune system disorders are a result of either low activity or over activity of the immune system and include well known conditions, such as lupus and rheumatoid arthritis. OSA occurs when throat muscles relax temporarily, narrowing or collapsing the airway and momentarily cutting off breathing during sleep. The main treatment for OSA is continuous positive airway pressure, or CPAP, which pumps air through a mask to keep the airway open. About 40% of patients can't tolerate CPAP. The results of this study may lead to better approaches to treatment and possibly new drug therapies.

Pre-Recorded Audio Messages Help Improve Outcomes For Patients With Heart Failure

Patients who are hospitalized with heart failure can reduce their odds of requiring re-hospitalization, a heart transplant, or death by reviewing recorded audio messages repeatedly about self-care at home, according to late breaking research presented on November 17, 2020 at the American Heart Association’s Scientific Sessions virtual meeting. “My Recorded On-Demand Audio Discharge Instructions (MyROAD®)” is a re-playable audio card containing information for patients with heart failure who have been discharged from the hospital. The MyROAD audio card begins with a general statement and then has four sections about diet, physical activity, medication, and self-monitoring behaviors specific to heart failure to help answer frequently asked questions about the condition and what to expect at home. The study was conducted by investigators at the Office of Nursing Research and Innovation at the Cleveland Clinic Health System. It involved a randomized controlled trial of about 1,000 patients (average age 72.8 years, 58.7% male) who were hospitalized with heart failure at four sites in Northeast Ohio.

return to November 2020 trends

DEVELOPMENTS IN HIGHER EDUCATION

Kristen Truong

November 23, 2020

Whenever a new President of the United States takes office, a key responsibility is to select cabinet nominees and directors of various agencies. Many positions must be confirmed by the Senate, which means that it will be important to learn which political party will control that chamber in January. Regardless of whether Democrats or Republicans occupied the White House or controlled the House and Senate, no group has been successful in reauthorizing the Higher Education Act in recent years. That legislation last was reauthorized in 2008 for a five-year period. It will be interesting to see if the 117th Congress will enjoy more success in passing a bill that can be sent to the President to be enacted into law.

Viewed historically, the Department of Health, Education, and Welfare (HEW) was created on April 11, 1953. It lasted until the Department of Education Organization Act was signed into law by President Jimmy Carter, which provided for a separate Department of Education in 1979. HEW subsequently became the present day Department of Health and Human Services (HHS) on May 4, 1980. Along with a new Education Secretary, other political appointees will include Under Secretaries, Assistant Secretaries, and Deputy Secretaries, with a resultant impact on Department policy areas, including higher education and accreditation. These new officials can be expected to conduct a close review of policies implemented during the Trump administration with an inclination to modify priorities and possibly restore some regulations that were revised during the past four years. Accreditation is one of many higher education aspects that could be affected by such modifications. Another topic featured during Democratic primaries was to provide assistance to students burdened with educational debt as discussed below.

The Volume And Repayment Of Federal Student Loans

Between 1995 and 2017, the balance of outstanding federal student loan debt increased from $187 billion to $1.4 trillion (in 2017 dollars). During the Democratic primaries, several candidates expressed interest in providing financial assistance to lower the amount of debt for students. A report from the Congressional Budget Office (CBO) in November 2020 examines factors contributing to that growth, including changes to student loan policies, and how they affected borrowing and repayment. Much of the overall increase in borrowing occurred because the share of borrowers who attended for-profit schools increased substantially. Students who attended for-profit institutions were more likely to leave school without completing their programs and to fare worse in the job market than students who attended other types of schools. They also were more likely to default on their loans. Also, the incidence of default and participation in income-driven repayment plans, which limit how much borrowers must repay regardless of how much they borrow, increased over the period. Both of those factors resulted in larger outstanding student loan balances. The 117th Congress furnishes an opportunity to determine whether federal assistance should be provided as a means of lowering student loan debt.

Race And Ethnicity In Higher Education

The American Council on Education launched its Race and Ethnicity in Higher Education Project in 2019 with aims to: provide a data-informed foundation from which the higher education community can examine racial disparities in educational opportunities and outcomes; draw insights; raise new questions; and make the case for why it is vital to discuss racial equity gaps present in U.S. higher education. The Council released on November 16, 2020 its Race and Ethnicity in Higher Education: 2020 Supplement. The report examines over 150 indicators, looking at academic experiences and outcomes, and how these educational journeys differ, by race and ethnicity. Invited scholarly essays also provide further context around race and ethnicity in higher education that data alone cannot tell. A focus is on how average figures mask concentrations of debt, most notably held by more economically vulnerable populations, such as students who have not completed their degrees. Moreover, failure to disaggregate the borrower population ignores substantial portions of society whose student loan experience is quite different. Black borrowers and their families are accumulating more debt on average and their struggles with repayment result in some of the highest default rates. Data presented in the report may prove helpful to policymakers in efforts to address these kinds of disparities.

return to November 2020 trends

HEALTH REFORM DEVELOPMENTS

Kristen Truong

November 23, 2020

According to one definition in the Oxford English Dictionary (Third Edition), “reform is the action or process of making changes in an institution, organization, or aspect of social or political life, so as to remove errors, abuses, or other hindrances to proper performance” Viewed from that perspective, the term signifies an effort to make improvements. Although the U.S. in recent decades has made significant strides in the realm of health care through efforts to reduce the ranks of the uninsured, more work continues to be necessary. The Patient Protection and Affordable Care Act, also known as the ACA, that became law in 2010 represented an attempt to increase the number of individuals with health insurance, reduce costs, and improve quality. Some positive results were achieved, but not enough.

Apart from deliberate efforts by policymakers to bring about such improvements, unanticipated events also can play a decisive role. The COVID-19 pandemic that continues to wreak havoc across the entire U.S. in 2020 offers a vivid illustration of such an occurrence. Responses to the coronavirus have varied extensively depending on where individuals live, such as in mandates involving social lockdowns and wearing masks. Two different governmental approaches are characterized by having both upsides and downsides. A top-down orientation would place the federal government in charge of all major decisions affecting individual and community health status. An implicit assumption is that officials in Washington, DC have the expertise to devise plans that will work equally effectively in mid-town Manhattan and Los Angeles as they would in Wetumpka, Alabama and Valley City, North Dakota. An opposing point of view is that all major decision-making should be located at a more local level in order to take into account key demographic factors that distinguish inhabitants of different parts of this nation. Thus, COVID-19 furnishes an excellent opportunity to begin to give thorough consideration to whether a more unified approach to any future pandemics should be implemented instead of relying on what presently amounts to a series of disjointed state-by-state responses.

The U.S. Supreme Court And The Individual Mandate
Senate confirmation hearings on the nomination of Judge Amy Coney Barrett to occupy a seat on the U.S. Supreme Court revealed a concern by many Democrats that placing her on the federal bench would jeopardize the Affordable Care Act. In November 2020, in the case of California v. Texas, the high court undertook an effort to rule on the constitutionality of the ACA. The case was brought by a group of Republican-led states and is supported by the Trump administration. Their argument is that since Congress eliminated the individual tax mandate in 2017, the entire law now must be invalidated. Some members of the court, including Chief Justice John Roberts, signaled they would support allowing the individual mandate to be severed from the remainder of the 2010 health care law, meaning that the rest of the ACA would continue to exist.

What To Expect From A Biden Administration

According to a report from the Blue Cross Blue Shield Administration, millions of children have missed routine vaccinations this year, causing a precipitous drop in immunizations that threatens to leave communities throughout the U.S. at risk of losing protection against highly contagious diseases, including measles, whooping cough, and polio. Not only will health officials chosen by President Biden be involved in the distribution of coronavirus vaccines that become available, they will be faced with the task of ensuring that vaccinations against these other diseases achieve more acceptable levels.

Democrats will continue to control the U.S. House of Representatives in 2021-2022. If they can do likewise in the Senate, certain policy goals will be easier to achieve. Otherwise, it will be necessary to seek compromises with Republicans on the following issues that will require the passage of legislation: (1) Expand and support Affordable Care Act (ACA) coverage provisions, including the expansion of existing tax credits to more individuals. (2) Create a public insurance option for individuals to enroll voluntarily, with automatic enrollment for certain uninsured individuals and no premiums for Medicaid-eligible individuals in the 14 states that chose not to expand Medicaid, and (3) Lower the eligibility age for Medicare from 65 to 60 years. Apart from legislation, a tool that the new administration can use to influence coverage and other health reforms is waiver authority. The Centers for Medicare & Medicaid Services (CMS) have the ability to do so for both state Medicaid programs and for insurance reforms.

return to November 2020 trends

CHANGING OF THE GUARD

Kristen Truong

November 23, 2020

Elections have consequences and one them is that the locus of political power can undergo significant transformations. A shift from President Donald Trump’s occupancy of the White House to having former Vice President Joseph Biden become the next resident in January 2021 will have a major impact on what transpires in the new 117th Congress. Another important influence on what will occur there will depend on the outcome of two U.S. Senate races that are scheduled for January 5 in Georgia. Democrats will need both seats in order to attain the magic number 50. Once it is reached, Vice President-Elect Kamala Harris will become the tie-breaking vote. If Republicans are successful in retaining just one of those two seats, they will remain in control of the Senate, which will have a dramatic effect on the extent to which President-Elect Biden and his Democratic colleagues in the House of Representatives are able to have their desired legislative objectives enacted into law.

The next page of this newsletter provides some details of policy initiatives that Democrats have expressed a strong interest in achieving in the next session of Congress, such as additional pandemic aid, creating a government-run public insurance option, and lowering the Medicare-eligibility age to 60. A major function of Congress is to produce legislative bills in both chambers. Competition to reach the enactment stage is brisk as reflected in what occurred during 2019-2020 in the 116th Congress as of November 18, 2020.

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Prior to reaching agreement on the size of another package of financial aid in response to COVID-19, Congress found it necessary to agree on legislation to provide funding to prevent a federal government shutdown at the beginning of the new fiscal year on October 1, 2020. Legislators were successful in doing so by producing a $1.4 trillion stopgap spending measure to fund the federal government at current levels through December 11, 2020. Still pending is the necessity of completing work on the 12 annual appropriations bills for fiscal year 2021. A convenient way of doing so would be to agree to pass an omnibus appropriations package to fund the government through the end of September 2021.

An unknown when this article was written on November 17 is whether any members of Congress will become members of President-Elect Biden’s cabinet or take positions in government agencies. Apart from the upcoming Senate races in Georgia, it remains too soon to know the exact composition of both legislative chambers at the start of the next session of Congress in January.

return to November 2020 trends

COVID-19: A DELICATE COEVOLUTIONARY DANCE

Kristen Truong

November 23, 2020

Humans and viruses represent two highly dedicated coevolving foes that have been pitted against each other for millennia. An article published in the November 10, 2020 issue of Proceedings of the National Academy of Sciences of the USA aims to show how an evolutionary perspective can advance understanding of the progression and consequences of the COVID-19 pandemic. This objective is addressed by having a diverse group of scientists with expertise from evolutionary medicine to cultural evolution provide insights about the disease and its aftermath.

As an illustration, at a granular level, consideration is given to how viruses might affect social behavior, and how quarantine, ironically, could make humans susceptible to other maladies due to a lack of microbial exposure. A psychological level describes ways in which the pandemic can affect mating behavior, cooperation (or the lack thereof), and gender norms, and how disgust can be used better to activate “behavioral immunity” to combat disease spread. A cultural level discusses shifting cultural norms and how they might be harnessed more effectively to combat disease and the negative social consequences of COVID-19.

Fundamentally, the existential conflict waged between viruses and humans is a consequence of the fact that nutrients and the machinery of cellular reproduction in Homo sapiens offer irresistible targets for exploitation by smaller and faster evolving organisms. While viruses benefit from rapid replication rate and mutation potential that enable them to adapt quickly to exploit their hosts, natural selection has provided humans with a complex physiological system that can target viruses at a cellular level. It is significant that humans have proven to be exceptionally quite adept through displays of communication ability, intelligence, and innate curiosity in producing extraordinary scientific tools to erect insurmountable walls for limiting the spread of certain viral diseases.

As the authors indicate, an evolutionary perspective can be helpful in understanding the nature of the virus that currently plagues the earth, our own nature in responding to its threats, and the interactions between them. Such an approach to the pandemic furnishes a valuable lens through which it becomes possible to ascertain which strategies a virus might use, our countervailing strategies, and which additional strategies it will become imperative to acquire.

Ten insights are listed and described in the manuscript. They are: (1) the virus might alter host sociability, (2) “generation quarantine” may lack critical microbial exposures, (3) activating disgust can help combat disease, (4) the mating landscape is changing and there will be economic consequences from a decrease in birth rates, (5) gender norms are backsliding and gender inequality is increasing, (6) an increase in empathy and compassion is not guaranteed, (7) we have not evolved to seek the truth, (8) combating the pandemic requires its own evolutionary process, (9) cultural evolutionary forces impact COVID-19 severity, and (10) human progress continues. Essentially, the paper is a call to action and also an opportunity to make new beneficial discoveries to improve health status.

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HISPANIC GENDER DIFFERENCES IN HOSPITALIZED HEART PATIENTS

Kristen Truong

October 21, 2020

Trends Archives

More than 3,000,000 women in the U.S. die of heart failure (HF) annually. Women significantly are underrepresented in studies that inform practice guidelines, especially women hospitalized for HF despite associated negative outcomes. HF is common in Hispanic individuals, the largest ethnic minority group in this nation, who are mostly of Mexican origin. Since there were no studies of gender differences in Mexican-Hispanic persons hospitalized for HF, as reported in the September-October 2020 issue of the periodical Women’s Health Issues, researchers sought to describe gender differences in demographic and clinical characteristics, clinical presentation, treatment, in-hospital outcomes, and discharge status in Mexican-Hispanic patients hospitalized for HF.

Compared with men, women were equally affected by obesity, on average six years older (p < .01), and more likely to be widowed (31% vs 6%; p < .001). Women had significantly higher ejection fractions, more total comorbid conditions, more hyperlipidemia, more arthritis, more anxiety, and were less likely to be treated with digoxin and more likely to be treated with calcium channel blockers. At discharge, women were significantly less likely to receive an angiotensin-converting enzyme inhibitor or an aldosterone receptor blocker and had a higher systolic blood pressure. A conclusion reached from this investigation is that key gender differences in chronic illness burden, treatment, and discharge status were found, highlighting the heterogeneity of women with HF and the need for further gender-specific research to develop care strategies specific to women of all races and ethnicities.

Return to October 2020 TRENDS

BIG DATA, RESEARCH, AND ETHICS CHALLENGES FOR IRBs

Kristen Truong

October 21, 2020

Trends Archives

The increased use of big data has shifted the way in which biomedical research is designed and implemented. This kind of research has begun to pursue opportunities afforded by big data by relying on large‐scale databases, multiplication of data sources, advanced storage capacity, and novel computational tools that allow for high‐velocity data analytics. Big data also enable researchers to draw health insights from data sources that are not strictly medical, such as data from wearable trackers, social media, and Internet searches that open new prospects to accelerate health‐related research and potentially elicit breakthroughs that will benefit patients. Currently, a large portion of health‐related research depends on big data, while the novelty of techniques and methods brought by big data research brings new challenges to institutional review boards (IRBs). It is unclear, however, if those entities should be the responsible oversight bodies for big data research and, if so, which criteria they should use.

According to a manuscript published in the September-October 2020 issue of the journal Ethics & Human Research, big data investigations shift the way biomedical researchers design and carry out their studies because their work departs from the traditional research model since it is largely exploratory rather than hypothesis driven. The methodological novelty of big data research models brings new challenges and questions to IRBs, including whether they are the bodies responsible for assessing these projects. Given current technologies, analytic methods, and regulations, IRBs cannot take their traditional review frameworks as given since big data research models might not fit within the traditional national review policies for the protection of human subjects. Health-related big data research also challenges IRBs in referring to existing safeguards for ethics research, such as informed consent, privacy, confidentiality, and minimal risk. A threefold consideration is involved. First, individuals whose data are used in research often are not sufficiently informed concerning the use of their data. Second, breaches in data privacy and confidentiality represent a major source of risk stemming from the informational richness of large data repositories, which makes them a primary target for actors outside the research domain. Third, correlations arising from health‐related big data analytics can be abused by various actors for unethical purposes, such as discriminating against applicants to health insurance services or jobs based on health risk indicators.

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AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

Kristen Truong

October 21, 2020

Trends Archives

U.S. Women Living In Areas Devoid Of Proper Maternity Care

Maternity care deserts are characterized as being areas without hospitals that offer obstetric care, birth centers, or a specialized provider. According to a new report from the March of Dimes, these areas continue to be a problem in the U.S. as women die of pregnancy complications at rates higher than women in other high-income nations. More than 2.2 million women of childbearing age live in such deserts and an additional 4.8 million live in areas with limited access to maternity care. Women in the rural U.S. are especially at risk of giving birth without proper access to care. Also, there are more than four times as many rural counties that are maternity care deserts than urban counties, and only 8% of obstetrics providers report working in rural areas. At the same time, 1 in 3 women of childbearing age in a maternity care desert lives in an urban setting. The report can be obtained here.

Mental Health Of U.S. Adults

Three new data briefs from the CDC outline the state of mental health among U.S. adults in 2019. More than 1 in 7 of these individuals experienced some level of anxiety during 2019, before the pandemic, while nearly 1 in 5 reported depression. Additional information is as follows:

Anxiety: When asked about their anxiety symptoms in the two weeks prior to being surveyed, nearly 10% of adults reported mild anxiety, while around 3% reported severe forms of anxiety. Women and those aged 18-29 were most likely to report being anxious. The data brief can be obtained here.

Depression: Nearly 12% of respondents reported mild depression symptoms in the two weeks prior to being surveyed, while nearly 3% reported severe depression. White and Black adults were most likely to report depression than other racial groups. The data brief can be obtained here.

Treatment: Around 1 in 5 U.S. adults reported having any mental health treatment last year. Around 16% said they had taken some medication, while around 10% reported obtaining counseling. The data brief can be obtained here.

Integrating Systems And Sectors Toward Obesity Solutions

The Roundtable on Obesity Solutions of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine held a virtual public workshop, Integrating Systems and Sectors Toward Obesity Solutions, on April 6, 2020 (Part I), and June 30, 2020 (Part II). The event explored complex systems and contributing factors that can influence obesity, and shared real-life examples of applying systems thinking and systems science approaches to addressing obesity and population health and well-being. In Part I, speakers provided an overview of systems science theories and approaches and their application. In Part II, speakers discussed complex systems in society that have the potential to shape the public’s health and considered opportunities for systems change with regard to obesity solutions. Specifically, the workshop explored how factors such as power dynamics, structural racism, relationships, resources, place-based issues, policy, and political will affect systems that can influence obesity, as well as how these factors can have an impact on communications and cross-sector collaboration to address obesity. The Proceedings of the Workshop can obtained here.

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Kristen Truong

October 21, 2020

Trends Archives

American Adolescents And Mental Illness Treatment Variation

A new national investigation finds that many youth do not receive appropriate follow-up care soon after an initial insurance claim for a mental health condition. The study included data from more than two million children covered by Blue Cross Blue Shield. Of the more than 200,000 children in the study with at least one mental health claim, nearly 30% did not obtain any follow-up treatment in the three months after an initial claim. Published on September 29, 2020 in Proceedings of the National Academy of Sciences of the USA, the study examined insurance claims from children between the ages of 10 and 17 covered by Blue Cross Blue Shield. Of the more than two million children included in the study, nearly one in 10 had a claim related to mental illness between 2012 and 2018. Of those who were prescribed medication, 45% were given drugs that could be addictive or that were not FDA-approved for use in children. Having more psychiatrists in each child’s zip code increased the likelihood of medication treatment, while more therapists in the area increased the chances of therapy alone.

Alcohol-Induced Deaths Among Adults Aged 25 And Over: United States, 2000–2018

As reported in an October 2020 Data Brief from the National Center for Health Statistics, excessive alcohol consumption is a well-known risk factor for mortality and has been causally linked to many diseases, conditions, and injuries, including alcohol-attributable cancer, liver cirrhosis, and alcohol poisonings. Age-adjusted rates of alcohol-induced deaths among adults aged 25 and over were stable from 2000 to 2006, then increased 43% from 10.7 per 100,000 in 2006 to 15.3 in 2018. For both males and females, alcohol-induced death rates increased at a greater rate between 2000 and 2018 in rural compared with urban areas. Among males, the rate of alcohol-induced deaths was highest in large central metro areas in 2000 (21.3); by 2018, rates in medium (25.1) and small metro (25.9), micropolitan (26.7), and noncore (25.3) areas were highest. Among females, the rate of alcohol-induced deaths in noncore areas (4.4) was among the lowest in 2000; by 2018, rates in noncore areas had more than doubled (9.9).

HEALTH TECHNOLOGY CORNER

Use Of Holographic Imaging To Detect Viruses And Antibodies

A team of New York University scientists has developed a method using holographic imaging to detect both viruses and antibodies. This approach has the potential to aid in medical diagnoses and, specifically, those related to the COVID-19 pandemic. Holographic immunassays can be targeted for specific diseases by replacing protein A as a surface binding group with appropriate specific antigens, including peptides, proteins, or other biomolecules. Holographic analysis yields results faster and at lower cost by eliminating reagents, processing steps, and expertise needed to apply fluorescent labels while yielding quantitative results for antibody concentration without requiring extensive calibration. According to an article published on October 8, 2020 in the journal Soft Matter, if fully realized, this proposed test could be done in under 30 minutes, is highly accurate, and can be performed by minimally trained personnel. Moreover, the method can test for either the virus (current infection) or antibodies (immunity).

Cell Revival Following A Heart Attack

Extracellular vesicles (EVs), small membrane-bound particles released from cells, have been shown to have cardioprotective effects and are promising tools for the next generation of therapies for everything from autoimmune and neurodegenerative diseases to cancer and tissue injury. EVs derived from stem cells help heart cells recover after a heart attack. Exactly how they help and whether the beneficial effect is specific to EVs derived from stem cells has remained a mystery. Now, according to a study reported in the October 14, 2020 issue of the journal Science Translational Medicine, investigators from Harvard University have unraveled potential mechanisms behind the healing power of EVs and demonstrated their capacity not only to revive cells after a heart attack, but keep them functioning while deprived of oxygen during a heart attack. This functionality in human tissue was demonstrated using a heart-on-a-chip with embedded sensors that continuously tracked tissue contractions.

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DEVELOPMENTS IN HIGHER EDUCATION

Kristen Truong

October 21, 2020

Trends Archives

The beginning of the fall semester each year is highlighted by the return of college football. Due to COVID-19, many teams have decided to play fewer games this season compared to previous years. Some major conferences originally decided to postpone competition until 2021, but subsequently agreed to play a limited number of games later this year. Depending on the team, some players, coaches, and other personnel have tested positive for the virus, which led to decisions to postpone some contests to later dates. A common feature has been either to have no fans present in stadiums or to reduce the usual attendance drastically. Meanwhile, the non-football side of academic institution life also displays a considerable amount of variation regarding the volume of disease testing that occurs and whether to send students home who test positive or just quarantine them for different periods of time. Schools also vary on the proportion of students who decided to enroll for the fall semester. Each college and university is affected differently by reductions in revenue derived from tuition, housing, meals provision, and activity fees.

Fostering Research Integrity And The Responsible Conduct Of Research

As posted on October 19, 2020 in the Federal Register on pages 66341-66342, the Department of Health and Human Services (HHS), Office of Research Integrity (ORI) seeks information and comments from entities and individuals regarding activities that foster research integrity and promote the responsible conduct of research. In particular, ORI is interested in learning about best practices, challenges, and needs related to teaching the responsible conduct of research, promoting research integrity, and preventing research misconduct. ORI will use this information to support the goal of conducting outreach and developing educational resources that best support the Public Health Service (PHS) funded research community. Responses to the RFI must be received electronically no later than 5:00 p.m. ET on the 60th day following the date of publication of this announcement in the Federal Register.

The following three categories are of interest:

Using Training and Education To Foster Research Integrity (ORI seeks to understand key challenges to using training and educational efforts to foster a climate that encourages research integrity and the responsible conduct of research.)

Research Integrity/Responsible Conduct of Research Program Administration and Facilitation of Training (ORI requests answers to 10 questions.)

Research Integrity/Responsible Conduct of Research Training Sessions (ORI seeks information on institutional experiences, practices, and needs.)

U.S. Department Of Education Launches 2021-2022 FAFSA Cycle

The U.S. Department of Education on October 1, 2020 released the 2021–2022 Free Application for Federal Student Aid (FAFSA) form as a means of providing information, tools, and resources to help students make informed decisions about their education options. This year, enhanced help topics provide even more guidance through the form. As a result of user feedback, many financial help topics on fafsa.gov feature images of the forms with relevant line numbers visually highlighted to help applicants navigate the FAFSA form. Additionally, skip-logic functionality means applicants see only the questions that pertain to them. The Department also furnishes other tools and resources designed to help students complete and submit the FAFSA form and make informed choices.

The Annual Student Loan Acknowledgment provides links to College Scoreboard where students can estimate their post-completion starting salary based on the school they plan to attend and the program in which they will enroll. For borrowers with existing loans, the Annual Student Loan Acknowledgment outlines how much they owe and how much more they can borrow, and grant recipients can see how much they have received and their remaining eligibility. Starting with the 2021–2022 award year, the Annual Student Loan Acknowledgment will be required before borrowers can receive a financial aid disbursement.

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HEALTH REFORM DEVELOPMENTS

Kristen Truong

October 21, 2020

Trends Archives

A decade has passed since the Patient Protection and Affordable Care Act (ACA) became law. This legislation continues to be controversial, however, as evidenced by a series of exchanges between members of the U.S. Senate Judiciary Committee and Judge Amy Coney Barrett, a nominee to the Supreme Court to fill a vacancy resulting from the death of Judge Ruth Bader Ginsburg. Democrats on the committee pressed her on her views regarding how she might vote on the case California v. Texas, which is scheduled for oral argument at the Supreme Court on November 10. These individuals are expected to vote against her confirmation because of a fear that she will be instrumental in overturning the ACA.

Apart from several attempts by Congressional Republicans over the past 10 years to repeal the ACA, this latest manifestation of opposition stems from a case, NFIB v. Sebelius, in which the deciding vote cast by Chief Justice John Roberts found that the individual mandate could not be justified under the constitution’s Commerce or Necessary and Proper clauses, but it could be upheld as an exercise of Congress’ taxing power. Since then, the 2017 Tax Cuts and Jobs Act set the mandate penalty at zero beginning in 2019. Subsequently, Attorneys General in 17 states argued in court that since the mandate no longer produces revenue and is not a tax, not only the mandate, but the entire law is unconstitutional. A district court agreed, indicating that the mandate was an essential part of the law, was not severable, thereby rendering the entire law as being unconstitutional. Next, the Fifth U.S. Circuit Court of Appeals allowed the Democrat-controlled House of Representatives to intervene to defend the ACA on appeal. That step led to a decision by the Supreme Court to accept a petition to conduct an immediate review.

Policies To Achieve Near-Universal Health Insurance Coverage

A report from the Congressional Budget Office (CBO) in October 2020 examines policy approaches to achieve near-universal health insurance coverage using some form of automatic coverage through a default plan. As defined by CBO, a proposal would achieve near-universal coverage if close to 99% of citizens and noncitizens who are lawfully present in this country were insured either by enrolling in a comprehensive major medical plan or government program or by receiving automatic coverage through a default plan. Proposals to achieve near-universal coverage would have two primary features. At a minimum, if they required premiums, those premiums would be subsidized for low- and moderate-income individuals, and would include a mandatory component that would not allow them to forgo coverage or that would provide such coverage automatically.

CBO organized existing proposals into four general approaches, ranging from one that would retain existing sources of coverage to one that would almost entirely replace the current system with a government-run program. All four approaches would provide automatic coverage to individuals who did not enroll in a plan on their own. Two approaches would fully subsidize coverage for lower-income people and partially subsidize coverage for middle-income and some higher-income people while retaining employment-based coverage. Another two approaches would fully subsidize coverage for individuals at all income levels.

Nationwide Evaluation Of Health Care Prices Paid By Private Health Plans

A new analysis from the RAND Corporation indicates that private health plans in the U.S. pay hospitals an average of 247% percent of what Medicare would pay for the same services at the same facilities. Wide variation exists in pricing among states (e.g., Michigan under 200% and Florida more than 325%). Addressing prices paid by employer-sponsored and other private insurance plans represents a tangible way to reduce health care spending. Where quality and convenience are comparable, employers can use network and benefit design approaches to move patient volume away from higher-priced, lower-value hospitals and hospital systems and toward lower-priced, higher-value providers. Employers also can use this information to reformulate how contracts are negotiated on their behalf. Various changes are not possible without price transparency information. Price transparency by itself will not be sufficient, however, if employers do not act on price information. In some cases, employers may need state or federal policy interventions to rebalance negotiating leverage between hospitals and their health plans.

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DUELING COVID-19 AID PACKAGES

Kristen Truong

October 21, 2020

Trends Archives

Prior to reaching agreement on the size of another package of financial aid in response to COVID-19, a more immediate test for Congress was to agree on legislation to provide funding to prevent a federal government shutdown at the start of a new fiscal year on October 1, 2020. Legislators were able to pass that test by producing a $1.4 trillion stopgap spending measure to fund the federal government at current levels through December 11 of this year. Still pending is the necessity of completing work on the 12 annual appropriations bills for fiscal year 2021 during the lame duck session of Congress that will follow the elections on November 3.

An effort to agree on the size of an aid package to address a wide range of problems stemming from the coronavirus has proved, however, to be much more challenging and nettlesome. Last May, the House of Representatives passed a $3.4 trillion stimulus bill (H.R.6800, the Health and Economic Recovery Omnibus Emergency Solutions Act or the HEROES Act) that included aid for state and local governments; rent and mortgage relief; expanded unemployment benefits and food assistance; another round of direct cash payments of up to $1,200 to individuals; and a two-year federal backstop of subsidies to support health plans and coverage of job-based insurance premiums between March and next January for workers who have been laid off or furloughed. Senate Republicans responded by indicating that among many other objections, they would not approve an extension and were in no hurry to pass more relief. Instead, they were in favor of gauging the impact of previously passed stimulus packages before considering additional legislation.

By early July, Republicans expressed interest in having coronavirus legislation that would prioritize COVID-19 testing and vaccine research, and address expanded unemployment benefits that were scheduled to expire at the end of July. By the middle of that month, White House officials and Senate Republicans agreed that relief legislation should cost $1 trillion or less. By the end of July, GOP members favored having another round of loans for the Paycheck Protection Program (PPP), stimulus checks for individual Americans, and provisions to protect seniors from a potential increase in their health insurance premiums. White House officials were less enthusiastic about including stimulus check eligibility and a possible payroll tax cut. By early August, congressional Republicans favored a $1.1 trillion stimulus package. Unable to overcome an impasse on Capitol Hill, as reported in the July/August 2020 issue of this newsletter, President Trump released a series of executive orders in August to address several current needs.

By the start of October, House Democrats were willing to trim their aid package to $2.2 trillion, but Senate Republicans showed little interest in providing funds at that level. House Speaker Nancy Pelosi (D-CA) and Treasury Secretary Steven Mnuchin met to negotiate on several occasions, but could not finalize an agreement. Next, Republicans agreed to increase their proposal to $1.6 trillion, but Democrats insisted a larger amount is needed. By October 9, President Trump was willing to go as high as $1.88 trillion, but as of the time this issue of the newsletter is being distributed, final results still are pending.

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IN SEARCH OF CONNECTIONS

Kristen Truong

October 21, 2020

Trends Archives

Epidemiologists serve as detectives in rooting out the causes of disease. Not only are they often successful in identifying the multifactorial origins of specific causes of morbidity and mortality, they also can show how all aspects of a given condition are connected. A death certificate may contain the singular label cardiovascular disease, but a more accurate descriptor involves connections among several factors in the form of social determinants, such as inadequate nutrition, residence in unsafe neighborhoods, unemployment/underemployment, and exposure to pollution.

A vivid illustration from the public health realm of the importance of establishing connections is an epidemiological study of a deadly cholera outbreak in London in 1854. John Snow was convinced that the disease was caused by a contagious agent. He conducted interviews with residents of the area about their water sources, while meticulously recording the time, person, and place of disease events. He integrated the interview data with disease-event information and concluded that cholera was occurring mostly in victims who were drawing their water from the Broad Street water pump. He convinced skeptical authorities to remove the pump handle and the outbreak was brought to a halt.

As described in a paper appearing in the October 5, 2020 issue of the journal Current Biology, it wasn’t until 30 years later when the renowned microbe hunter, Robert Koch, independently discovered V. cholerae that its responsibility for cholera became common knowledge. Koch and his contemporaries were part of the golden age of microbe hunting during which microscopes were trained onto many disease states and linked with their causative pathogens, leading to the widespread acceptance of the germ theory of disease underpinned by his famous four postulates. Snow’s pioneering epidemiological methods for tracing disease now could be coupled with microbiological methods that identify causative pathogens. Connecting disease and infection proved to be pivotal for the management of infectious agents.

Rolling ahead to the current pandemic, weekly reports from the CDC indicate that for only 6% of deaths, COVID-19 is the only cause mentioned. Other underlying conditions or comorbidities, such as influenza/pneumonia, respiratory failure, hypertension, diabetes, and cardiac arrest account for the remaining 94% of mortality. Another important connection pertains to perceived collateral damage from social lockdown policies that are associated with lower childhood vaccination rates, fewer cancer screenings, and deteriorating mental health that can lead to greater excess mortality.

Moreover, a steady growth in the size of the human population has led to increased encroachment on forests that previously were inhabited only by animals. Greater exposure to zoonotic diseases that jump from other species (e.g., bats) to humans can result in more infectious disease epidemics and pandemics. Successful virus mutations in humans then can be transmitted from human to human. Hence, it is likely our species is in it for the long haul regarding infectious disease outbreaks.

Return to October 2020 TRENDS

THE NEUROBIOLOGY OF SOCIAL DISTANCE

Kristen Truong

September 22, 2020

Social isolation on a massive scale is a product of responding to COVID-19 while recognizing that the social environment has a dramatic impact on a sense of life satisfaction and well-being. When under duress, human resilience depends on the richness and strength of social connections, along with active engagement in groups and communities. Evidence that has emerged in recent years makes it abundantly clear that perceived social isolation (i.e., loneliness) may be the most potent threat to survival and longevity. The World Health Organization in 2019 declared that loneliness is a major health concern worldwide and the United Kingdom recently appointed its first Minister of Loneliness. A manuscript published in the September 2020 issue of the journal Trends in Cognitive Sciences highlights the benefits of social bonds; the choreographies of bond creation and maintenance; and the neurocognitive basis of social isolation and its deep consequences for mental and physical health. Accumulating evidence indicates that friendships are a conditio sine qua non for health quality. The tighter someone is embedded in a network of friends, the less likely it is that an individual will become ill. The higher the level of social capital, the faster the recovery time will be after becoming ill, the quicker to recover from surgery, and the longer the length of life.

Researchers in the journal study explored the neurobiology of social isolation and the consequences it has for health and psychological well-being. They outline the evidence for the many benefits of social interaction and consider why an individual cannot have an unlimited number of friends, even though they are highly beneficial. These investigators also briefly survey the behavioral patterns that play a central role in creating and maintaining strong social bonds. Finally, an examination is performed of key neurobiological mechanisms underlying social interplay and the impact that social deprivation has on them.

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