April 22, 2021

OBTAINABLE RESOURCES

April 22, 2021

Applying Systems Thinking To Regenerative Medicine

Regenerative medicine products, which are intended to repair or replace damaged cells or tissues in the body, include a range of therapeutic approaches such as cell- and gene-based therapies, engineered tissues, and non-biologic constructs. It often is challenging to characterize these products properly for a number of reasons, and there often is not a definitive correlation between what is measured and the clinical outcome for these complex products. A systems-focused approach can help better define the mechanistic parameters involved in the biological outcome and allows for the collection and use of more relevant data. Systems thinking is a multidisciplinary effort and can incorporate tools and knowledge from the fields of data science, biology, engineering, manufacturing, regulatory science, and clinical research and therefore requires the use of disparate data sources. Given these considerations, the Forum on Regenerative Medicine of the National Academies of Sciences, Engineering, and Medicine convened experts across disciplines for a two-day virtual workshop in October 2020 to explore systems thinking approaches and how they may be applied to support the identification of relevant quality attributes that can help optimize manufacturing and streamline regulatory processes for regenerative medicine. Workshop proceedings summarize key information and can be obtained here.

Shared Equity Leadership: Making Equity Everyone’s Work

Decades of programmatic efforts and interventions have failed to make a difference in the success of racially minoritized, low-income, and first-generation students, whose populations are increasing on college campuses. Higher education remains profoundly inequitable, and institutions have not made the transformational changes necessary to create truly inclusive environments and equitable outcomes for students. A prominent lever for change is campus leadership. According to a report from the American Council on Education (ACE), a description is provided on how broadly inclusive and collaborative approaches to leadership are necessary to achieve equitable outcomes. At the heart of shared equity leadership (SEL) is the notion of personal journey toward critical consciousness, in which leaders develop or strengthen a commitment to equity through their identity, personal experiences, or relationships, and learning. This paper reports on the results of a multiple-case study of leaders at eight institutions that are experimenting with shared approaches to equity leadership. It describes some emerging outcomes from the participating campuses, and offers recommendations for leaders interested in trying this approach. The report can be obtained here.

Black And White Patients In Hospitals With Worse Safety Conditions

Identifying and reducing racial disparities in the quality of health care is a necessary (if insufficient) step toward reversing the effects of systemic racism on racial health inequities in America. A study investigates differences in Black and White patient safety measures using complete hospital discharge records from 26 states in 2017 and further examines whether some differences in patient safety quality can be attributed to the hospitals into which they are admitted. Black patients experienced higher rates of adverse patient safety events on 6 of 11 patient safety measures, including 5 of 7 surgery-related patient safety measures. For 9 of 11 patient safety indicators, including 6 of 7 surgery-related patient safety indicators, Black patients were significantly less likely to be admitted into hospitals classified as“high quality” (i.e., hospitals best at minimizing patient safety risks based on the median value of each patient safety indicator). The findings suggest that current policies have been ineffective in addressing inequities in the quality of inpatient care. The report can be obtained here.

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Kristen Truong

April 22, 2021

Childhood Disability In The United States, 2019

According to a report issued on March 25, 2021 from the United States Census Bureau, the percentage of children with a disability in the U.S. increased between 2008 and 2019, from 3.9% to 4.3%. The most common type of disability among children five years and older in 2019 was cognitive difficulty. In 2019, disability rates in the U.S. were highest among American Indian and Alaska Native children (5.9%) and lowest among Asian children (2.3%). Childhood disability rates were lower among foreign-born children (3.2%) than among native-born children (4.2%) and lower among native-born children with one or more foreign-born parents (3.1%), relative to native-born children with only native-born parents (4.5%). While children in poverty were more likely to have a disability than children above the poverty threshold in 2008 and 2019, the prevalence of disability significantly increased for both groups over this period. The highest prevalence rates were in the South and the Northeast and the lowest rate was in the West.

U.S. Births: Final Data For 2019

Data from the National Vital Statistics Report on March 23, 2021 from the CDC show that a total of 3,747,540 births were registered in the United States in 2019, down 1% from 2018. The general fertility rate declined from 2018 to 58.3 births per 1,000 women aged 15–44 in 2019. The birth rate for females aged 15– 19 fell 4% between 2018 and 2019. Birth rates declined for women aged 20–34 and increased for women aged 35–44 for 2018–2019. The total fertility rate declined to 1,706.0 births per 1,000 women in 2019. Birth rates declined for both married and unmarried women from 2018 to 2019. The percentage of women who began prenatal care in the first trimester of pregnancy rose to 77.6% in 2019. The percentage of all women who smoked during pregnancy declined to 6.0%. The cesarean delivery rate decreased to 31.7% in 2019. Medicaid was the source of payment for 42.1% of all births in 2019. The rate of low birthweight essentially was unchanged from 2018 at 8.31%.

HEALTH TECHNOLOGY CORNER

Electronic Skin From Flexibility To A Sense Of Touch

Materials scientists represent another group engaged in efforts to defeat the coronavirus. A team at Northwestern University in Evanston, IL develops soft, flexible, skin-like materials with health-monitoring applications. According to an article published on March 23, 2021 in the journal Nature, one device that is designed to sit in the hollow at the base of the throat, is a wireless, Bluetooth-connected piece of polymer and circuitry that provides real-time monitoring of talking, breathing, heart rate, and other vital signs, which could be used in individuals who have had a stroke and require speech therapy. A previously unanswered question was whether the device also could be customized to spot symptoms of the coronavirus SARS-CoV -2. The short answer was ‘yes’. Some 400 of the devices are being used in Chicago to help identify early signs of COVID-19 in front-line health workers, as well as for disease monitoring in patients. Furthermore, the design has been tweaked to assess how coughing rates change in patients with COVID-19.

Genome-Wide Programmable Transcriptional Memory By CRISPR-Based Epigenome Editing

The epigenome plays a central role in many diseases, from viral infection to cancer. This entity consists of proteins and small molecules that latch onto DNA and control when and where genes are switched on or off. A general approach for heritably altering gene expression may lead someday to powerful epigenetic therapies. The endeavor involves modifying CRISPR's basic architecture to extend its reach beyond the genome. According to a paper published April 9, 2021, in the journal Cell, researchers at UC San Francisco and the Whitehead Institute describe a novel CRISPR-based tool called "CRISPRoff," which allows scientists to switch off almost any gene in human cells without making a single edit to the genetic code. The researchers also show that once a gene is switched off, it remains inert in the cell's descendants for hundreds of generations, unless it is switched back on with a complementary tool called CRISPRon, that also is described in the paper. This approach doesn't involve any DNA edits and is likely to be safer than conventional CRISPR therapeutics.

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DEVELOPMENTS IN HIGHER EDUCATION

Kristen Truong

April 22, 2021

Regardless of which political party controls the White House and the two chambers of Congress, an enormous amount of activity occurs every year in the form of proposed legislation, regulatory directives from governmental agencies, and Executive Orders by the President of the United States. A vast assortment of law firms, lobbying organizations, and interest groups participate in the quest to achieve desired policy outcomes. The new Biden Administration is up and running at full speed and can be expected to pursue not only its preferred objectives, but also to push back against policies implemented during the previous Administration that it does not view favorably. The topic of sexual harassment in the educational sector furnishes an apt illustration of such activities.

Dating back to 2011, the Obama Administration issued an informal letter that defined sexual harassment as a form of sex discrimination actionable under Title IX. A follow-up letter in April 2014 provided additional guidance on schools’ responsibilities under Title IX to address sexual violence as a form of sexual harassment. Opponents criticized the letters for undermining due process rights for involved parties. Multiple court cases then were launched that aimed at striking down campus procedures resulting from this guidance. The Trump Administration joined the controversy by having the U.S. Department of Education issue a final rule in May 2020 to address the responsibilities of college campuses and K-12 schools under Title IX of the Education Amendments of 1972. The rule aimed to ensure protections for sexual assault survivors and require thorough investigations of sexual assault incidents. It also was designed to align Title IX requirements with court precedents and provide fundamental protections for due process.

On March 8, 2021, President Biden issued an Executive Order directing the Department to review and consider suspending, revising, or rescinding the Department’s rule entitled “Nondiscrimination on the Basis of Sex in Education Programs or Activities Receiving Federal Financial Assistance.” This issue of sexual harassment and violence has attracted considerable attention in recent years. For example, listening sessions about the contents of this rule began in 2017, which was followed by the Department’s release of that proposed rule in November 2018. The next year and a half led to the Department’s receiving and reviewing more than 224,000 public comments, and the Office of Management and Budget conducted 102 stakeholder meetings. The final rule in May 2020 specified how recipients of Federal financial assistance covered by Title IX, including elementary and secondary schools, along with postsecondary institutions, must respond to allegations of sexual harassment, including sexual assault. The rule amounted to 2,033 pages, which include the regulation itself, the Department’s legal rationale, and its response to thousands of public comments.

Valuable Services Provided By Governmental Data Gathering Agencies

Political party affiliation and personal ideology often combine to produce assessments about the value of government in the lives of the citizenry. An old joke involves being unwittingly trapped in one’s vehicle in a traffic jam and unable to see what is ahead to explain its cause. A liberal Democrat might conclude that what is needed to remedy the situation is to have a cop at the disruptive scene, while a conservative Republican might conclude that the mess is because there is a cop up there. A general truism in American life is that Democrats often look favorably upon increasing the amount of governmental activity to deal effectively with chronic problems, such as uneven allocation of health care and educational services, while Republicans may be more inclined to view the government as the cause of such problems rather than the cure. Often lost in these debates is a recognition that a function governmental agencies perform quite well, especially at the federal level, is to collect data that inform the implementation of sound public policies. A good example is the Integrated Postsecondary Education Data System (IPEDS) developed by the National Center for Education Statistics. This entity serves as the primary source of information about U.S. higher education institutions. An example of a useful IPEDS tool is a Trend Generator to view trends on most frequently asked subject areas including: Enrollment, Completions, Graduation Rates, Employees and Staff, Institutional Revenues, and Financial Aid.

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HEALTH REFORM DEVELOPMENTS

Kristen Truong

April 22, 2021

Health Reform initiatives constitute the equivalent of a conceptual three-legged stool: increase access to health care through the provision of insurance coverage, lower the ever-rising rate at which health expenditures grow, and improve health care quality. Regarding the issue of quality, a story in the April 17-18, 2021 issue of the Wall Street Journal highlighted the fact that no commercial airline in the U.S. has had a fatal crash since 2009. During that 12-year period, U.S. airlines have accomplished an astonishing feat. They carried more than eight billion passengers without a fatal crash. Numbers of this sort once were considered unimaginable, even among the most optimistic safety experts. This achievement was the result of a sweeping safety reassessment amounting to a revolution in thinking sparked by a small group of senior federal regulators, top industry executives, and pilots-union leaders after a series of high-profile fatal crashes in the mid-1990s. Health care is an entirely different industry, but it represents a sector that is no stranger to loss of life and injury through errors made in providing care. A good question is whether comparable lessons can be learned that will produce a turnaround similar to what the air travel sector has been able to accomplish.

The Role Of Government In Enhancing Health Care Safety

Health systems and clinicians increasingly are becoming aware of new federal rules that mandate offering patients access to the notes clinicians write in electronic health records (open notes). Taking effect on April 5, 2021, these rules enact the bipartisan 21st Century Cures Act by aiming to increase interoperability and ensure greater transparency in health care. According to an article published in April 2021 in The Joint Commission Journal on Quality and Patient Safety, many patients reading notes following office visits are enthusiastic about this new experience, citing several benefits that have clinical significance. They report remembering more details of encounters, feeling more in control, being better able to manage their care, and completing tests and referrals more effectively. Forty percent of patients share notes they read with others, and family care partners who access these notes report in even higher percentages than the patients themselves that it can help ease the burdens of care management. As the open notes practice evolves, it can expect to be associated with clinical improvements, for example, a majority of patients who read their notes reported understanding their medications better, and 15% reported improved adherence to their medicines.

The Centers for Medicare & Medicaid Services play an enormous role in the provision and financing of health care services. Among its many essential functions, each year it identifies hospitals that will receive lower payments for a year under the Hospital-Acquired Conditions Reduction Program because they had higher rates of infections and patient injuries. The government assesses the rates of infections, blood clots, sepsis cases, bedsores, hip fractures, and other complications that occur in hospitals, which might have been prevented. Medicare reduces every payment by 1% for those hospitals over the course of the federal fiscal year, which runs from the beginning of each October to the end of September of the following year.

A Public Option For Health Insurance In The Nongroup Marketplaces

Some Members of Congress have proposed introducing a federally administered health insurance plan, or “public option,” to compete with private plans in the nongroup marketplaces established by the Affordable Care Act. A new report from the Congressional Budget Office (CBO) describes key design considerations and some of their major implications. The agency explains how those design choices would affect the: public option’s premiums; private insurers’ premiums and participation in the market-places; health insurance coverage in the United States; and federal outlays and revenues. The insurance risk of the public option would be borne by the federal government by having it bear financial responsibility for medical claims covered by the plan. Certain design choices could, for example, result in a public option that used the federal government’s ability to set administered prices and its purchasing power to offer marketplace enrollees a lower-premium plan with a broad provider network. Such a plan would most likely encourage a significant number of individuals to enroll in the public option. Other design choices could be made to establish a public option that was similar to private plans in premiums and provider networks.

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BIDEN ADMINISTRATION PROPOSED BUDGET

Kristen Truong

April 22, 2021

The Biden Administration submitted on April 9, 2021 an overview of the President’s request for fiscal year 2022 discretionary funding. This preliminary budget indicates proposed top-line funding for departments and agencies, including a proposed $769 billion in nondefense discretionary spending, which would represent a 16% increase over FY 2021. Later this spring, a more detailed budget request is expected to be released. Overall, the discretionary budget would restore non-defense discretionary funding to 3.3% of GDP, roughly equal to the historical average over the last 30 years, while providing robust funding for national defense and other instruments of national power, including diplomacy, development, and economic statecraft that enhance the effectiveness of national defense spending and promote national security.

Over the years, many budget proposals submitted to Congress by each President often are pronounced dead on arrival. Members of both chambers usually have their own favorite ideas regarding which priorities should be funded. Major differences also characterize what Democrats and Republicans hope to be achieved through spending. Some proposed highlights for legislators to begin considering for FY 2022, which begins on October 1 of this year are as follows.

The NIH would receive $51 billion, including $6.5 billion to establish a new Advanced Research Projects Agency for Health (ARPA-H) with an intended focus on cancer, diabetes, and Alzheimer’s disease.
The CDC would be awarded $8.7 billion, which represents the largest budget authority increase in approximately 20 years.
The Department of Education would obtain $102.8 billion, a 41% increase over the 2021 enacted level.

April 8, 2021 marked the introduction in the U.S. House of Representatives of the Student Loan Forgiveness for Frontline Health Workers Act (H.R. 2418). The bill was referred to the Committee on Education and Labor, and the Committees on Financial Services, and Ways and Means. The purpose of this legislation is to alleviate the burden of student loan debt resulting from medical/professional health care training for frontline health workers who have made significant contributions to the ongoing health response against COVID-19.

Since the March 2021 issue of this newsletter was distributed, ASAHP has joined several other organizations in issuing statements that: (1) oppose efforts currently being pursued in several states to suppress voting by qualified voters, (2) urge Congress to provide $1.51 billion for the Health Resources and Services Administration (HRSA) Title VII health professions and Title VIII nursing workforce development programs for FY 2022, and (3) request Congress to double the maximum Pell Grant and index the grant to inflation to ensure its value does not diminish over time.

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THE HEALTH WORKFORCE: AN IMPLICIT ASSUMPTION

Kristen Truong

April 22, 2021

Whenever major health legislation becomes law, such as the Patient Protection and Affordable Care Act of 2010, all too frequently the focus almost exclusively is on providing health insurance coverage and slowing the rate of increase in health care expenditures. An implicit assumption is that if every individual in the U.S. population was given a health insurance card, major health problems essentially might disappear. Unfortunately, provision of health care requires the presence of a sufficient cadre of competent practitioners. This fact is an important element in the overall equation that does not always receive the amount of attention warranted.

A sine qua non of sound policymaking is the existence of high quality data. Pockets of relevant health information exist, but they may be restricted to professions, such as medicine and what is obtainable in certain states. For example, since 2015 the Association of American Medical Colleges (AAMC) has commissioned annual reports of national physician workforce projections prepared by independent experts. The purpose of doing so is threefold: update and improve workforce projections; present new analyses that reflect physicians and key issues, such as the evolving health care system and the changing demographic composition of the workforce; and identify future directions for research. Not many other kinds of health professions are able to capitalize on having information of this nature.

At the state level, data derived from decennial censuses by the U.S. Census Bureau make it possible to determine demographic shifts. State out-migration patterns may result from the flight of youth seeking improved employment prospects elsewhere, while leaving behind jurisdictions that have a growing proportion of older persons characterized by experiencing one or more chronic health problems. Few states are capable, however, of tracking increases or declines in the number of different health professional groups that provide clinical services for patients needing care. The Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill serves as an example of an academic resource that benefits state legislators and health department officials in addressing workforce concerns.

Some contributors to ASAHP’s Journal of Allied Health occasionally may be searching for suitable topics for the submission of articles. Suggestions of possible future manuscripts that might be of interest to the journal’s readership are: issues involving recruitment and retention of both faculty and students; supply and distribution of selected health professionals in rural areas; roles filled by various personnel in the provision of healthcare services; identification of gaps in workforce data availability by profession and projected time periods needed to promote improved data collection and reporting; how roles have adapted to fewer in-person visits and more use of distance technology and ways in which changes are being influenced by regulatory and payment policies; redeployments, furloughs, and layoffs, among other work status changes for health care personnel across different settings during a pandemic and other emergency situations; and skills needed to use telehealth by the health workforce effectively in primary care.

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FUTURE TIME PERSPECTIVE IN MID–TO-LATER LIFE

Kristen Truong

March 22, 2021

Future time perspective (FTP), or the way individuals orient to and consider their futures, is considered fundamental to motivation and well-being. Given FTP’s relevance to healthy adaptation, recent work has described its contributing factors, especially age, health, and personality. Yet, the extant literature is plagued by inconsistent FTP conceptualizations and sample characteristics. Specifically, although relationships between FTP and its contributors seem dependent on both FTP conceptualization and sample life-span stage, much existing literature emphasizes differing FTP conceptualizations and young adult samples, complicating cross-study conclusions. As reported in the March 2021 issue of The Journals of Gerontology: Series B, Psychological Sciences and Social Sciences, a study was conducted that explored the ways in which age, health, and personality simultaneously contribute to FTP in mid-to-later life with machine-learning techniques.

Until now, no studies regarding how these factors jointly contribute to FTP have been conducted and it is unclear as to whether complex interactions exist among these predictors in their relation to FTP. Personality, especially neuroticism, extraversion, conscientiousness, and agreeableness, had the most influence on FTP. Age and health were not among the most salient FTP contributors in mid-to-later life. Furthermore, decision tree analyses uncovered interactive effects of personality. Several profiles of neuroticism, extraversion, and conscientiousness were linked with differing FTP levels. Although current literature has indicated that FTP, age, and health are inextricably tied, these results indicate that there is more variability to be explained in FTP, perhaps especially when looking within specific age groups.

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EMERGING CLINICAL ROLE OF WEARABLES

Kristen Truong

March 22, 2021

Wearable technology, also known as “wearable devices” or simply “wearables,” generally refers to any miniaturized electronic device that easily can be donned on and off the body, or incorporated into clothing or other body-worn accessories. While wearables have established utility in the fitness, gaming, and entertainment industries, their role in the healthcare environment remains less clear. According to a manuscript published on March 10, 2021 online in the journal npj Digital Medicine, to date most commercially available wearables are limited in scope, tracking one or two health-related variables, and have yet to produce accurate measurement of many markers of health status that they attempt to assess such as heart rate variability, nutrition, and mood. To the extent that wearables overcome these limitations, they hold much promise towards expanding the clinical repertoire of patient-specific measures. They are considered an important tool for the future of precision health. For example, physical activity is a well-established marker of current health status and future health risks, it is a useful estimate of real-life functional performance, and it has been tracked in health research using body-worn sensors for many decades. Given the ubiquity of physical activity monitors, it is surprising their effective incorporation into clinical care remains a challenge, especially in face of the multiple known health benefits of physical activity and the many healthcare scenarios where physical activity information has a clinical use.

Two of the NIH’s Big Data to Knowledge Centers of Excellence organized a workshop on potential clinical applications of wearables to address various challenges. A workgroup from diverse backgrounds (hospital administration, clinical medicine, academia, insurance, and the commercial device industry) discussed two successful digital health interventions that involve wearables to identify common features responsible for their success. Seven features were identified including: a clearly defined problem, integration into a system of healthcare delivery, technology support, personalized experience, focus on end-user experience, alignment with reimbursement models, and inclusion of clinician champions. For each feature, problems are outlined within the patient domain that are addressed per feature and specific representative examples of solutions are provided for these problems by the two sample digital health programs. Health providers and systems eager to establish new models of care inclusive of wearables may consider these features during program design. A better understanding of these features is necessary to guide future clinical applications of wearable technology.

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OBTAINABLE RESOURCES

Kristen Truong

March 22, 2021

Academic Incentives And Research Impact

The road to tenure can be viewed as paved with measures of peer-reviewed publications, first authorships, citations, journal impact, grant funding, and national or international reputation. According to the author of a paper that was prepared for the organization AcademyHealth, a proposition is offered that for the most part, measures of research impact on societal problems are missing in action from performance evaluation criteria within academic disciplines. So, the paper aims to encourage creative thinking around academic incentives and research impact by challenging existing orthodoxies, generating new insights, and stimulating a productive debate within the discipline. As a means of accomplishing these objectives, cases are presented to explore efforts challenging the status quo of academic research incentives and realigning them to focus more on societal impact. The cases are organized around a system-, institutional-, and individual-level framework. Examples are furnished that highlight the range of efforts explored more fully in the paper to align academic incentives with societal impact. The paper can be obtained here.

Student Debt And Its Impact On Black Americans

As more students take out more loans at higher amounts, the issue of student debt and proposals to mitigate it has taken greater prominence in national policy debates. According to a report from the Brookings Institution, the problem especially is pertinent for Black households, for whom a lack of generational wealth risks making student debt a long-term financial burden. After graduation, loans quickly balloon, delaying or even preventing Black Americans from building wealth. Based on the 2018 Survey of Income and Program Participation (SIPP), the authors indicate that because student debt disproportionately harms the wealth-poor, and the Black wealth-poor in particular, student debt cancellation could be a powerful tool in dismantling institutional discrimination and shrinking racial wealth disparities if implemented correctly. They center the Black experience in their consideration of student loan debt and draw from their own analysis to argue for debt cancellation that is not means-tested (predicated upon household income) as an important mechanism for closing the racial wealth gap. They compare the effects of cancelling debt against the status quo, and at three different levels of intervention: 1) $10,000 cancelled for all (as President Joe Biden has proposed); 2) up to $50,000 cancelled based on means-testing for households earning under $100,000 and a sliding scale cancellation for households earning up to $250,000 (as Senator Elizabeth Warren [D-MA] has proposed); and 3) total debt cancellation (as Senator Bernie Sanders [I-Vt.] has proposed). They find that the more student debt that is cancelled, the greater the effect increasing Black wealth, particularly for households below the wealth median. The report can be obtained here.

Adult Family Care As An Alternative To Nursing Homes

A report from AARP that was written for consumers, advocates, and state policy staff, summarizes some key features of Adult Family Care (AFC), along with ideas for expanding its availability. Individuals who need long-term services and supports want alternatives to nursing homes as living options. AFC, which is not as well known among consumers as home care and assisted living, gives older adults and persons with disabilities a viable alternative. In AFC, sometimes called adult foster care or adult family homes, residents live full-time in a house or other small residential setting where they receive assistance with activities of daily living, personal care, and help with medications and other health care tasks, in collaboration with health care professionals. More than 40 years ago, Oregon and Washington were the first states to establish AFCs as an option for both private pay residents and those receiving public funds. Many jurisdictions have had difficulty recruiting providers and consumers since then. The report can be obtained here.

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Kristen Truong

March 22, 2021

U.S. State Life Tables, 2018

A new report from the National Center for Health Statistics presents the first set of annual complete period life tables for each of the 50 states and the District of Columbia (D.C.) for the year 2018. The period life table does not represent the mortality experience of an actual birth cohort. Rather, it presents what would happen to a hypothetical cohort if it experienced throughout its entire life the mortality conditions of a particular period in time. Life tables were produced for the total, male, and female populations of each state and D.C. based on age-specific death rates for that year. Among the 50 states and the District of Columbia, Hawaii had the highest life expectancy at birth, 81.0 years in 2018, and West Virginia had the lowest, 74.4 years. Life expectancy at age 65 ranged from 17.5 years in Kentucky to 21.1 years in Hawaii. Life expectancy at birth was higher for females in all states and D.C. The difference in life expectancy between females and males ranged from 3.8 years in Utah to 6.2 years in New Mexico.

Prescription Drugs For Older Adults And The Risk Of Falling

Published on February 3, 2021 in Pharmacoepidemiology and Drug Safety, a study reported from the University at Buffalo examined data on deaths due to falls and prescription fills among patients 65 and older from the National Vital Statistics System and the Medical Expenditure Panel Survey. Age-adjusted mortality due to falls increased from 29.40 per 100,000 in 1999 to 63.27 per 100,000 in 2017. The percent of individuals who received at least one prescription for a fall risk increasing drug, including antidepressants, anticonvulsants, antipsychotics, antihypertensives (for high blood pressure), opioids, sedative hypnotics, and benzodiazepines (tranquilizers such as Valium and Xanax) increased from 57% in 1999 to 94% in 2017. Fall risk increasing drugs may partially explain the increase in mortality due to falls, but cannot be firmly concluded from the current study. Future research involving nationally representative person‐level data are needed.

HEALTH TECHNOLOGY CORNER

Sex Differences In Neurodegenerative Diseases

Many neurodegenerative diseases, including Alzheimer's disease, Parkinson's disease, multiple sclerosis, and motor neuron disease, demonstrate clear sexual dimorphisms. While sex as a biological variable must now be included in animal studies, sex rarely is included in in vitro models of human neurodegenerative disease. A review published on March 16, 2021 online in APL Bioengineering describes these sex-related differences in neurodegenerative diseases and the blood–brain barrier (BBB), whose dysfunction is linked to neurodegenerative disease development and progression. The authors from the University of Maryland highlight a growing body of research suggesting sex differences play roles in how patients respond to these ailments. The authors note that some research suggests the barrier can be stronger in women than men, and the barriers in men and women are built and behave differently. They hope their article will serve as a reminder across the sciences, that accounting for sex differences leads to better results.

Female College Athletes And Traumatic Brain Injury

Female athletes are under-studied in the field of concussion research, despite evidence of higher injury prevalence and longer recovery time. Hormonal fluctuations caused by the natural menstrual cycle (MC) or hormonal contraceptive (HC) use have an impact on both post-injury symptoms and neuroimaging findings, but the relationships among hormone, symptoms, and brain-based measures have not been jointly considered in concussion studies. A preliminary investigation from the Northwestern University Feinberg School of Medicine published on February 24, 2021 in the Journal of Neurotrauma compared cerebral blood flow (CBF) measured with arterial spin labeling between concussed female club athletes 3–10 days after mild traumatic brain injury (mTBI) and demographic, HC/MC matched controls (CON). Researchers tested whether CBF statistically mediates the relationship between progesterone serum levels and post-injury symptoms, which may support a hypothesis for that hormone's role in neuroprotection. The findings support a hypothesis for its having a neuroprotective role after concussion and highlight the importance of controlling for the effects of sex hormones in future concussion studies.

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DEVELOPMENTS IN HIGHER EDUCATION

Kristen Truong

March 22, 2021

Another section of this newsletter indicates that the $1.9 trillion COVID-19 relief legislation called the American Rescue Plan Act (P.L. 117-2) was signed into law by President Joe Biden on March 11, 2021. One of its provisions is Section 2003, Higher Education Emergency Relief Fund. The amount of $39,584,570,000 will be made available through September 30, 2023, for making allocations for colleges and college students. Institutions receiving aid must dedicate at least half of the funding for emergency financial aid grants to prevent hunger, homelessness, and other hardships that students are facing because of the pandemic. Funds also can be used for general expenditures for institutions of higher education to cover those expenses associated with a disruption in services or operations related to coronavirus, including defraying expenses caused by lost revenue and reimbursing expenses already incurred.

The public health workforce consists of a great many different kinds of health professionals. Section 2501, Funding For Public Health Workforce will furnish $7,660,000,000, to remain available until expended, to carry out activities related to establishing, expanding, and sustaining a public health workforce, including by making awards to State, local, and territorial public health departments. The money shall be used for costs, including wages and benefits, related to the recruiting, hiring, and training of individuals to serve as case investigators, contact tracers, social support specialists, community health workers, public health nurses, disease intervention specialists, epidemiologists, program managers, laboratory personnel, informaticians, communication and policy experts, and any other positions as may be required to prevent, prepare for, and respond to COVID–19. This financial support is aimed at personnel who are employed by governmental public health departments and nonprofit private or public organizations with demonstrated expertise in implementing public health programs, particularly in medically underserved areas.

Counting U.S. Postsecondary And Secondary Credentials

The organization Credential Engine since 2017 has been engaged in laying bare an increasingly complex and confusing landscape of U.S. credentials, and to create the building blocks to make reliable and useful credential information more accessible for students, workers, and the employers who hire them. Part of the effort has consisted in creating a common taxonomy, or schema, through the Credential Transparency Description Language (CTDL) that allows individuals to make “apples-to-apples” comparisons between and among credentials, making it possible to map connecting points between credentials, competencies, jobs, education, and training opportunities. The driving force has been a lack of clarity about what exactly is available in education and training, the value of credentials in the labor market, and what enables certain individuals to benefit from those opportunities more than others. The CTDL is regarded as the standard language through which these million unique credentials and their competencies can be connected, compared, and contrasted, from evaluating whether a credential leads to a specific career and higher wages or if it leads to a higher-level credential, enhancing economic momentum and mobility.

Some Impacts Of COVID-19 On Higher Education

New international student enrollment in the United States and online outside the United States decreased by 43% in Fall 2020. Many international students studying at U.S. institutions took advantage of opportunities to begin their studies remotely. Ninety percent of institutions reported international student deferrals in Fall 2020. Respondents indicated that nearly 40,000 students had deferred enrollment to a future term. (Source: Institute of International Education)
The drop in the number of undergraduates enrolled in the fall of 2020 was 3.6% or a decrease of 360,000 students from a year earlier. (Source: National Student Clearinghouse Research Center)
Colleges and universities closed out 2020 with continued job losses, resulting in a 13% drop of 650,000 workers since February of that year. (Source: Bureau of Labor Statistics)

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HEALTH REFORM DEVELOPMENTS

Kristen Truong

March 22, 2021

Congress represents a fascinating portion of American life. Elected officials in both chambers find themselves on every major issue needing to decide whether their vote will advance the interests of their supporters in congressional districts and states back home, who made it possible for them to be elected, or have it enhance the welfare of the nation as a whole. Conflicts of this nature arise all the time. For example, improving the environment would seem to be a goal with widespread appeal, but if it means seriously damaging the fossil fuel industry in a state that is heavily dependent on jobs and revenues from oil, coal, and gas economic activities, it becomes less easy for officials from there to cast votes that favor the nation over the locale. Doing so usually will result in a rapid, undesired exit from political office following the next election.

Despite several decades of efforts on Capitol Hill to ensure that all inhabitants of the U.S. have adequate health insurance coverage, many individuals continue to lack that form of protection. Congress is balanced evenly in the number of Democrats and Republicans in the Senate while the House tilts slightly in favor of the Democrats numerically. As reported on March 5, 2021 in the New England Journal of Medicine, on the issue of universal health insurance coverage, the two parties’ constituents appear to be sharply divided. Nearly nine in 10 Democrats (87%) reported that they believe it is the responsibility of the government to ensure all individuals in the U.S. have health insurance coverage, a view shared by fewer than one in four Republicans (23%). Among Democrats, 75% reported that they prefer a health insurance system mostly run by the government, whereas 79% of Republicans reported that they prefer a system based mostly on private health insurance.

Regarding specific coverage proposals, Democrats expressed support for the following: building on the Affordable Care Act (ACA) [93%], Medicare-for-All (85%), and a Medicare buy-in to the ACA referred to as “the public option” (82%). In contrast, only 30% of Republicans expressed support for building on the ACA and 28% supported Medicare-for-All. While 62% of Republicans reported that they support a Medicare buy-in to the ACA, that support does not represent an endorsement of the notion that government should ensure universal coverage. Also, 64% of Republicans reported that they support replacing the ACA with a state-based private health insurance alternative compared with 36% of Democrats. These substantial differences do not bode well for implementing major changes any time soon in how health insurance is provided in this nation.

Medicare Payment Advisory Commission (MedPAC)

Apart from highly trained staff members in Congress, elected officials often profit from advice provided by other sources, one of which is MedPAC. The Commission is an independent congressional agency established by the Balanced Budget Act of 1997 (P.L. 105–33) to advise the Congress on issues affecting the Medicare program. Besides advising that body on payments to health plans participating in the Medicare Advantage program and providers in Medicare’s traditional fee-for-service program, MedPAC has additional responsibilities that involve analyzing access to care, quality of care, and other issues affecting the Medicare program. Its 17 members can seek to influence the work of Congress in several ways, one of which is the issuance of reports in March and June each year that contain various Commission recommendations.

The report sent on March 15, 2021 consists of 14 chapters that deal with such matters as: the near-term consequences of the coronavirus pandemic and the longer-term effects of Medicare spending on the federal budget and the program’s financial sustainability, and an option for Medicare’s coverage of telehealth services after the coronavirus public health emergency. Both the short- and long-term contexts for the Medicare program are sobering. Because of the pandemic, in the short term, beneficiaries are at particular risk. Patients over 65 are more likely to suffer severe COVID-19 cases and complications and die than those who are younger and have fewer comorbidities. Long-term, the financial future of the Medicare program was already problematic, but as a result of job losses, in 2020 the Congressional Budget Office projected that Medicare’s Hospital Insurance Trust Fund will become insolvent by 2024, two years earlier than previously expected.

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AMERICAN RESCUE PLAN BECOMES LAW

Kristen Truong

March 22, 2021

The American Rescue Plan Act (P.L. 117-2) was signed into law by President Joe Biden on March 11, 2021. A $1.9 trillion COVID-19 relief package, a final version of this legislation (H.R. 1319) was passed by the House of Representatives on a 220-211 vote on March 10 after the Senate voted 50-49 to amend the House’s initial version on March 6. No Republicans supported the legislation. Representative Jared Golden (D-ME) was the only Democrat to oppose it. A 1,149-page House Report of the Committee on the Budget, together with Minority Views, accompanied H.R. 1319. Among the key provisions of this law are the following in rounded numbers:

$48 billion for COVID-19 testing and tracing
$7.5 billion for the Centers for Disease Control and Prevention’s (CDC) vaccine distribution effort
$1.75 billion for the CDC to increase genome sequencing of SARS-CoV-2 for variant surveillance
$7.7 billion in awards under the Department of Health and Human Services to state, local, and territorial health departments to establish, expand, and sustain the public health workforce
$140 million in a one-time supplemental appropriation for HRSA training programs to address and prevent suicide, burnout, mental health conditions, and substance use disorders affecting the health workforce
$40 billion for the Higher Education Emergency Relief Fund

The bill also expands access to health care by providing tax subsidies to a wider range of individuals and families who purchase health insurance on the markets established under the Affordable Care Act (ACA). Additionally, P.L. 117-2 temporarily covers the entire cost of COBRA premiums for individuals who lose their jobs and incentivizes additional states to expand Medicaid as allowed under the ACA.

According to a report issued by the Congressional Budget Office (CBO) in March 2021, by the end of fiscal year 2021 on September 30, federal debt held by the public is projected to equal 102% of gross domestic product (GDP). If current laws governing taxes and spending generally remain unchanged, debt would equal 107% of GDP in 2031, its highest level in the nation’s history. Growth in outlays would outpace growth in revenues in subsequent decades, leading to growing budget deficits over the long term. As a result, federal debt would continue to increase, exceeding 200% of GDP by 2051.

Eventually, the federal government will have to create a means of paying for benefits flowing from the American Rescue Plan Act, along with pandemic-related expenditures from legislation enacted in 2020. Three ways of doing so are to: increase borrowing, raise taxes, and reduce other kinds of federal spending. Both near and distant future actions by Congress will determine what steps will be taken.

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HEALTH CARE COMPLEXITY AND UNCERTAINTY

Kristen Truong

March 22, 2021

Two distinguishing characteristics of the health care sphere are complexity and uncertainty. Last month’s issue of this newsletter contained a discussion of a term known as the prodrome, a period in biomedical research wherein an individual experiences some symptoms of an illness before meeting formal diagnostic criteria. It ends once a patient meets such criteria and is diagnosed with a disorder. Diagnostic standards are consequential. Not only can they label and stigmatize, they have the power to confer or deny access to social resources. Related features include fluidity and malleability, with the boundaries between health and illness subject to redefinition and reorganization.

Neuroscientific research suggests the presence of prodromal phases for a growing list of conditions, including schizophrenia and autism. Another example of possible complexity and uncertainty is schizoaffective disorder (SAD), a controversial diagnosis. Debate continues over its conceptualization, with some experts viewing SAD as an independent disorder, while others see it as either a form of schizophrenia or a mood disorder. If the focus is on an episode (DSM-IV, Diagnostic and Statistical Manual of Mental Disorders) rather than on the longitudinal course of the illness (DSM-V), this difference likely could lead to changed rates of diagnosis of SAD, but controversy remains over classification.

A paper appearing on February 16 of this year in the journal Theoretical Medicine and Bioethics indicates that which concept of disease is assumed has implications for what conditions count as diseases and, by extension, who may be regarded as having a disease (disease judgements) and who may be accorded the social privileges and personal responsibilities associated with being sick (sickness judgements). The authors consider an ideal diagnostic test for coronavirus disease (COVID-19) infection regarding four groups of individuals: (1) positive and asymptomatic, (2) positive and symptomatic, (3) negative, and (4) untested, showing how different concepts of disease have an impact on the disease and sickness judgements for these groups.

The third edition of the DSM in 1981 contained a definition of mental disorder that included a harm requirement (necessitating distress or disability to the individual) so that homosexuality could be coherently eliminated from the catalogue of diseases. This move changed the applicability of what is called disease judgement. Given that homosexuality does not cause harm and is therefore not a disease, according to the current definition of mental disorder, individuals who are homosexual cannot be regarded as having a disease. Concepts of disease also have implications for what are called sickness judgements about how the rights and restrictions associated with forms of sickness are attributed to individuals by virtue of their condition (e.g., entitlement to treatment and reimbursements, or the obligation to surrender one’s driving license). Sickness is the social aspect of disease. While disease and sickness judgements do not always correspond, the concept of disease places constraints on what counts as sickness. Thus, attainment of greater clarity among these concepts has the potential to improve clinical care.

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IMPLICATIONS OF GENETIC TESTING FOR SUICIDE RISK

Kristen Truong

February 22, 2021

The article on page one of this issue of TRENDS has a reference to how research soon may allow calculation of polygenic risk scores (PRS) for suicide death. Data reported in a study in the February 2021 issue of the journal Nature Genetic Medicine indicate that suicide claims the lives of over 47,000 individuals annually in the U.S. and the national rate has increased by 33% between 1999 and 2017. Genetic factors are viewed as playing a major role in suicide risk, with an estimated heritability of close to 50% for suicide death and as much as 30% for suicide attempt. Research during the past decade has begun to characterize genetic variation associated with suicide and suicide attempts. Notably, this genetic risk seems independent of variants associated with developing depression or other mental illnesses. Similar to other psychiatric genetic research, suicide research has not yet identified well-replicated genes and gene pathways leading to functional mechanisms, but increasing momentum and support for large-scale research suggests that investigators rapidly are approaching this goal.

Even before specific risk genes and pathways are discovered, studies of suicide risk may allow the calculation of polygenic risk scores for suicidality. Once these data are available, they may rapidly be commercialized and marketed to the public as direct-to-consumer testing that currently is not subject to extensive regulation. Given these rapid developments, there is an urgency to understanding how individuals may interpret and act on this information. The aforementioned journal article reports the results of initial focus group research related to knowledge about and perceived acceptability of genetic testing for suicide risk among suicide attempt survivors and family members of individuals who died of suicide. The findings from the study highlight the importance of extensive engagement with potential stakeholders before such genetic technologies are made available for clinical or public use.

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THE PRODOME: DIAGNOSIS, DISADVANTAGE, AND BIOMEDICAL AMBIGUITY

Kristen Truong

February 22, 2021

According to an article published in the March 2021 issue of the journal Society and Mental Health, diagnostic standards are consequential, as diagnoses can label and stigmatize, while conferring or denying access to social resources. Diagnostic criteria also are fluid and malleable, with the boundaries between health and illness subject to redefinition and reorganization. Technology may be an engine driving such redefinition of diagnoses. Viewed from that perspective, science and technology can create, reveal, or redefine disorders, making some diagnoses possible while hindering others. In this article, the author engages with the intersection of science and diagnosis by demonstrating how the prodrome, an emerging phase of illness characterized by neuroscientific research, creates problems for patients, their families, and health care institutions. In biomedical research, the prodrome is a period wherein someone experiences some symptoms of an illness before meeting formal diagnostic criteria. The prodrome ends once a patient meets formal criteria and is diagnosed with a disorder. It is of biomedical interest because these symptoms might provide advanced notice of impending illness.

The focus of this particular article is on Huntington Disease (HD), while acknowledging that neuroscientific research suggests the presence of prodromal phases for a growing list of conditions, including schizophrenia and autism. In this instance, the prodrome is examined from the standpoint of its social, experiential, and institutional consequences. Based on interviews with individuals and their informal caregivers, an explanation is provided regarding how the prodrome is a site of healthcare disadvantage. Although participants suffer from psychiatric and cognitive prodromal symptoms (e.g., hallucinations, mood changes) and associated challenges (e.g., job loss), they do not receive necessary support because they do not meet formal diagnostic criteria. The prodrome is viewed as being connected to: (1) the inability to access health care, (2) the inability to access health resources, (3) the depletion of personal resources, and (4) extensive caregiver burden and burnout. The HD prodrome also provides a contrast to research on the negative repercussions of diagnostic expansion, as prodromal individuals report struggling with symptoms that are well-characterized in neuroscientific research, but remain unacknowledged and under supported by health care institutions. An argument is advanced that prodromal individuals are shut out of health services as a result of such institutional ambiguities.

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OBTAINABLE RESOURCES

Kristen Truong

February 22, 2021

Voluntary Support Of Education

Since 1957, the Voluntary Support of Education (VSE) annual survey from the Council for Advancement and Support of Education (CASE) has collected data on fundraising outcomes in higher education institutions in the United States. It is regarded as the definitive source of information on philanthropic support of those institutions. Data from the survey are used to estimate total charitable support of all institutions of higher education in the nation, including nonrespondents. Survey respondents must adhere to the Reporting Standards and Management Guidelines, first published jointly with the National Association of College and University Business Officers (NACUBO) in 1982. CASE updated the standards in 1996, 2004, and 2009. According to the VSE survey, voluntary support of higher education institutions in the United States essentially was flat in the fiscal year that, for most institutions, ended June 30, 2020. While support edged down two-tenths of a percent, at $49.50 billion, nearly half, 48.6%, of responding institutions reported that giving rose in 2020. A CASE analysis of institutions that responded for the past four reporting cycles reveals that varying frequencies of rising and falling gift receipts are the norm. Indeed, even an institution that posts lower levels of giving in a particular year may have had a good year. Sometimes a very large gift the previous year results in a percentage decline that is not really a negative event. The report can be obtained here.

National Healthcare Quality And Disparities Report

The National Healthcare Quality And Disparities Report Chartbook On Patient Safety is the product of collaboration among agencies across the U.S. Department of Health and Human Services (HHS). It is part of a family of documents and tools that support the National Healthcare Quality and Disparities Report (NHQDR). The NHQDR is an annual document to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). The NHQDR provides a comprehensive overview of the quality of health care received by the general U.S. population and disparities in care experienced by different racial and socioeconomic groups. The purpose of the reports is to assess the performance of the U.S. health care system and to identify areas of strengths and weaknesses along three main axes: access to health care, quality of health care, and NHQDR priorities. The reports are based on more than 250 measures of quality and disparities covering a broad array of health care services and settings. Data generally cover 2000 through 2018. The reports are produced with the help of a Federal Interagency Work Group led by the Agency for Healthcare Research and Quality (AHRQ) and submitted on behalf of the Secretary of the U.S. Department of Health and Human Services (HHS). Chartbooks are organized around six Priority Areas. Patient Safety is one of them. They are interrelated and work to support all priority areas and can support necessary and critical improvements in making care safer. The Chartbook can be obtained here.

50-State Survey Of Telehealth Commercial Insurance Laws

States are stepping up requirements that insurers pay for telehealth at the same rate as in-person services, according to a new report from Foley and Lardner. Four more states required payment parity amid the pandemic last year, bringing the total to 14 states. The law firm argues that without such laws, insurers might set reimbursement rates so low that health providers feel no incentive to adopt telehealth. State-mandated coverage of text messages, images, and other “asynchronous health care” also has grown, with 27 now requiring reimbursement. Telehealth has skyrocketed, driven by patient concerns about contracting the virus during in-person visits to clinics or doctors’ offices. What remains unknown is whether Congress and the Biden Administration will make permanent some of the temporary federal payment policies set for the pandemic once it subsides. The report can be obtained here.

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Kristen Truong

February 22, 2021

Sexual Orientation Disparities In Risk Factors For Adverse COVID-19–Related Outcomes

Sexual minority individuals experience health disparities associated with sexual stigma and discrimination. Lesbian, gay, and bisexual persons in the U.S. have higher self-reported prevalence of several underlying health conditions associated with severe COVID-19 outcomes, compared to heterosexual persons, according to the February 5, 2021 issue of Morbidity and Mortality Weekly Reports. Between 2017 and 2019, sexual minorities, whether part of the overall population or among racial and ethnic minority groups, reported higher rates of asthma, chronic obstructive pulmonary disease, stroke, kidney disease, cancer and heart disease. Based on these findings, CDC indicated that including information on sexual orientation and gender identity, along with race and ethnicity, in COVID-19 data collections could improve knowledge about disparities in these communities. Current surveillance systems lack information on sexual orientation, hampering examination of COVID-19–associated disparities among sexual minority adults.

Instant Death More Common In Absence Of Physical Exercise

Heart disease is the leading cause of death globally and prevention is a major public health priority. Until recently, an aspect involving little information has been the effect of an active versus sedentary lifestyle on the immediate course of a heart attack. Now, there is evidence that an active lifestyle is linked with a lower chance of dying immediately from a heart attack based on a study published on February 12, 2021 in the European Journal of Preventive Cardiology. Researchers used data from 10 European observational cohorts including healthy participants with a baseline assessment of physical activity who had a heart attack during follow-up, a total of 28,140 individuals. While 17.7% died within 28 days of their heart attack, 62.3% of them died instantly. Patients who had engaged in moderate and high levels of leisure-time physical activity had a 33% and 45% lower risk of instant death compared to sedentary individuals. These numbers were 36% and 28%, respectively at 28 days.

HEALTH TECHNOLOGY CORNER

Identifying Candidates For Drug Repurposing For SARS-CoV-2

When COVID-19 arrived, researchers began seeking effective treatments, but producing new drugs can be a lengthy process. The only expedient option may be to repurpose existing medications. As reported on February 15, 2021 in the journal Nature Communications, a team from MIT's Department of Electrical Engineering and Computer Science, the Institute for Data, Systems and Society, and the Broad Institute of MIT and Harvard developed a machine learning-based approach to identify drugs already on the market that potentially could be repurposed to fight COVID-19, particularly in the elderly. Given that SARS-CoV-2 pathogenicity is highly age-dependent, it is critical to integrate aging signatures into drug discovery platforms. To identify robust druggable protein targets, researchers propose a principled causal framework that makes use of multiple data modalities. The investigators pinpointed the protein RIPK1 as a promising target for COVID-19 drugs, and they identified three approved drugs that act on the expression of RIPK1.

Affordable CRISPR App Reveals Unintended Mutations At Site Of CRISPR Gene Repair

Scientists have developed an affordable, downloadable app that scans for potential unintended mistakes when CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats) is used to repair mutations that cause disease. During CRISPR-directed gene editing, multiple gene repair mechanisms interact to produce a wide and largely unpredictable variety of sequence changes across an edited population of cells. Shortcomings inherent to previously available proposal-based insertion and deletion (indel) analysis software necessitated the development of a more comprehensive tool that could detect a larger range and variety of indels while maintaining the ease of use of tools currently available. As reported on February 10, 2021 in The CRISPR Journal, researchers developed Deconvolution of Complex DNA Repair (DECODR) to determine the identities and positions of inserted and deleted bases in DNA extracts from both clonally expanded and bulk cell populations. The software is accurate in making these determinations.

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DEVELOPMENTS IN HIGHER EDUCATION

Kristen Truong

February 22, 2021

During the campaign for the presidency in the 2020 election, several Democrat candidates expressed an interest in taking actions that will have a strong impact on higher education, such as making it free for many students at public institutions. According to a study released in January 2021 that was commissioned by the Campaign for Free College, it is estimated that if a plan supported by President Biden ever becomes law, enrollment at four-year private institutions over “several years” would be reduced by 12.3%. During the same period, enrollment at four-year public institutions would increase by 17.7%. Unfortunately, not all institutions in the private sector would be able to withstand a shift of this magnitude and it is anticipated that some of them would be forced to close their doors permanently.

Public institutions also experience some unique problems of their own, such as a steady decline over the period of many years in obtaining financial support from state governments. A related concern is that by increasing enrollment at these schools, it is highly likely that additional resources will be required to accommodate the growth in student numbers. The Biden plan does not take that possibility into account while based on recent history, it seems unlikely that support from state governments will be available to reduce the added cost burden. Related policy developments entail the provision of health insurance coverage for state residents who lack it. Medicaid programs, which are funded jointly by the federal government and the states, already exert a heavy toll on finances in many states. As some jurisdictions around the U.S. struggle in their efforts to cope with ever rising health care expenditures, their ability to support the higher education sphere is lessened concomitantly.

Forgiveness Of Student Debt

A related higher education policy issue is to forgive some portion of student debt incurred by individuals who found it necessary to borrow money to meet costs associated with attending colleges and universities. Similar to supporting free education at public institutions, Democrat candidates during the 2020 campaign for the presidency were in favor of reducing the $1.6 trillion in student debt that currently exists. Most of that amount was made by the Treasury Department and is held by the U.S. government. A portion of the total represents loans that originally were made by private lenders and guaranteed by the federal government. President Biden is in favor of forgiving both kinds of loans and has indicated that he is in favor of doing so in a manner that would be covered by federal taxpayers.

Assuming such a policy is enacted, it is reasonable to ask in the name of equity which groups should be the chosen beneficiaries. One segment consists of post-baccalaureate students who in pursuit of higher degrees awarded by prestigious business schools, law schools, and medical schools assume mountains of educational debt. The other side of the coin is that upon completion of their studies, they tend to be in a favorable position to earn highly satisfactory levels of income during their subsequent professional careers. Should their debt-oriented financial plight be viewed with the same degree of concern as students who are less fortunate? For example, proposed forms of debt absolution, such as writing off as much as $50,000 per student, will not be as beneficial for large numbers of individuals who decided not to attend college or who instead chose to work either before or during their college years to offset educational costs.

Vaccinating College Students

It is not all that uncommon to see photographs of students attending crowded social events while not wearing masks. Not generally perceived as a group that will suffer the worst effects of the coronavirus if they become infected, a bigger concern is the potential they have to be part of the super spreader portion of the community. Now that more colleges and universities have reopened their campuses, institutions such as the University of California, Berkeley; University of Massachusetts at Amherst; and the University of North Carolina at Chapel Hill have found it advisable to impose lockdowns in residence halls and encourage students to avoid travel. A related issue is the possibility of ensuring that students are vaccinated prior to leaving campus at semester’s end to prevent them from spreading the disease to older individuals.

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HEALTH REFORM DEVELOPMENTS

Kristen Truong

February 22, 2021

During the early days of cinematography, it was common for the lights in a movie theater to be turned on as an employee mounted the stage to make the following announcement, “One minute please while we change reels.” Federal health policy in the United States often is implemented in a similar manner. Regardless of the many alterations made during any presidential administration, as soon as a new president arrives on the scene from the opposing political party, several items are at a high risk of being reversed. Some examples of changes that have been made by the Biden Administration are as follows:

The regular Affordable Care Act sign-up period ended on December 15, but President Biden signed an executive order launching a special 90-day enrollment period for ACA coverage, which began on February 15. The Administration seeks to increase public awareness of the extended timeframe through a $50 million marketing campaign.

An executive order directs the U.S. Department of Health and Human Services (HHS) to review the interoperability of public health data systems across the nation. The objective is to improve COVID data sharing throughout the federal government, enhance vaccine distribution, and increase the understanding of the scope of the pandemic in communities throughout the country.

The following rules proposed by the Centers for Medicare and Medicaid Services (CMS) during the Trump administration have been withdrawn: Conditions for Coverage for End-Stage Renal Disease Facilities—Third Party Payments; Strengthening Oversight of Accrediting Organizations (AO) and Preventing AO Conflict of Interest, and Related Provisions; and Revisions to Medicare Part A Enrollments.

Unwinding Medicaid Work Requirements

The Biden Administration has expressed strong interest in beginning the process of rolling back Medicaid work requirements, an initiative developed when President Trump was in office, which generally mandated that beneficiaries log 20 or more hours on a job, look for work, perform community service, or take educational classes to be eligible for Medicaid benefits. Kentucky, Arkansas, and Nebraska are among 12 states that received federal approval to impose such requirements, although some plans were blocked by the courts. A possibility remains that some states may elect to challenge these roll back efforts.

Concentration Of Health Care Expenditures

A significant portion of health legislation is aimed at controlling health care costs. In the newest Statistical Brief, data from the Agency for Healthcare Research and Quality (AHRQ) Medical Expenditure Panel Survey Household Component (MEPS-HC) describe the overall concentration of health care expenses across the U.S. civilian noninstitutionalized population in 2018. Spending on health care that year accounted for 17.7% of the U.S. gross domestic product, yet the majority of this spending was concentrated in a small percentage of the population. Older individuals disproportionately were represented in the higher healthcare spending tiers. Among the entire U.S. civilian noninstitutionalized population in 2018, 16.8% were 65 and older, while 22.6% were under age 18. Among the top 5% of spenders, however, 39.0% were 65 and older, while only 5.8% were children under age 18. In contrast, among the bottom 50% of spenders, 30.6% were children while only 6.0% were 65 years and older.

Steady growth in the portion of individuals age 65 and older in the population will have an impact on efforts to lower health care spending due to the amount of money that will be spent on addressing their health care needs. The most commonly treated condition among the top 5% percent of spenders in 2018 was hypertension (48.8%), followed by osteoarthritis/other non-traumatic joint disorders (44%), and nervous system disorders (40.0%). While these conditions are the most common among high spenders, they are not necessarily the most expensive ones to treat. Instead, the top spending group is more likely to include patients with multiple chronic conditions or expensive treatments (e.g., surgeries, and hospitalizations) related to these conditions.

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More April 2021 TRENDS Articles

THE HEALTH WORKFORCE: AN IMPLICIT ASSUMPTION

BIDEN ADMINISTRATION PROPOSED BUDGET

HEALTH REFORM DEVELOPMENTS

DEVELOPMENTS IN HIGHER EDUCATION

QUICK STAT (SHORT, TIMELY, AND TOPICAL)