OBTAINABLE RESOURCES

Long-Term Services And Supports Needed By Retirees

The goal of a three-part series of briefs from the Center for Retirement Research at Boston College is to help retirees, their families, and policymakers better understand the likelihood that 65-year-olds, over the course of their retirement, will experience disability that seems manageable, catastrophic, or somewhere in-between. The initial brief in June 2021 begins by describing the risk of needing different levels of support during retirement. The first section introduces the analysis. The second section explains the methodology, including how support needs are measured and classified. The third section describes the results: about one-fifth of retirees will need no support and one-quarter are likely to experience the type of severe needs that most patients dread. In between these two extremes, 22% will have low needs and 38% will have moderate needs. The brief can be obtained here.

The second brief in the series was released in September 2021. It explores the extent to which retirees’ financial and non-financial resources together could meet different levels of care needs. The first section provides an overview of the types of care older adults typically receive. The second section explains the methodology for estimating the support that various family members and financial resources can provide. The third section describes the results, and reports that, at age 65, only about one-fifth of retirees have the family and financial resources to cover high intensity care for at least three years and about one third do not have any resources at all. The second brief can be obtained here.

Journals Of Gerontology Scientific Articles On COVID-19

The Gerontological Society of America's highly cited, peer-reviewed journals are continuing to publish scientific articles on COVID-19. The following were published between August 16 and September 21, 2021 in the Journals of Gerontology, Series B: Psychological Sciences and Social Sciences:

COVID-19-Related Worries, Disruptions, And Depressive Symptoms Among Community-Dwelling Older Adults With Disabilities: What Makes The Difference? which discusses how the results supported the claim that the associations between COVID-19-related social disruptions and depressive symptoms can vary over time.

Physical Disability And Older Adults’ Perceived Food And Economic Insecurity During The COVID- 19 Pandemic, which discusses how older adults with more functional limitations were vulnerable to economic and food insecurity during the pandemic.

Changes In Older Adults’ Social Contact During The COVID-19 Pandemic, which discusses the importance of ensuring that communication technologies to maintain social ties are available to and usable by older adults, particularly for those living in residential care settings.

A National Study Of Racial-Ethnic Disparities In COVID-19 Concerns Among Older Americans: Evidence From The Health And Retirement Study, which discusses how more research and policy interventions are needed to lessen the disproportionate burden of COVID-19 experienced by older adults of racial-ethnic minority groups.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Emergency Department Visits Involving Dental Conditions, 2018

Oral health contributes to overall wellbeing and improved quality of life. Untreated poor dental health also can lead to negative general health outcomes. According to a statistical brief published on September 30, 2021 by the Agency for Healthcare Research and Quality, there were two million dental-related emergency department (ED) visits in the U.S. in 2018, accounting for 1.4% of the 143 million total ED visits. The vast majority of dental-related ED visits were treat and release (94.5%), with the remaining ED visits resulting in hospital admission (5.5%). Individuals aged 18–44 years had the highest rate of dental-related ED visits overall (1,107.4 per 100,000 population) compared with all other age groups. The rate of dental-related ED visits was more than 2.5 times higher for non-Hispanic Black individuals than for other race/ethnicity groups (1,362.4 vs. 520.9 or less per 100,000 population). Individuals residing in the lowest income communities (quartile 1) had the highest rate of dental-related ED visits (1,069.1 per 100,000 population).

Health Care Spending For Working Americans

Average annual health care spending for individuals with employer-sponsored insurance (ESI) rose 2.9% to $6,001 per person in 2019, according to the Health Care Cost Institute’s annual Health Care Cost and Utilization Report that was released in October 2021. Between 2015 and 2019 spending increased by 21.8% or $1,074 per person. While prices continued to grow each year, utilization of health care services declined slightly in 2019, leading to slower year-to-year spending growth. The report examines four groups of health care services. Of the four major categories, outpatient visits saw the highest spending increase from 2015 to 2019 (31.4%). Spending per person increased 14.8% over five years for professional services. Spending per person on inpatient admissions rose 14.4% between 2015 and 2019. Increases in prices and use led to a 31.4% increase in outpatient spending over five years. Spending on prescription drugs increased 28.4% over five years. Out-of-pocket spending increased $91 per person over five years.

HEALTH TECHNOLOGY CORNER

Near-Infrared Fluorogenic Spray For Rapid Tumor Sensing

The prognosis for a cancer patient who undergoes surgery is better if the surgeon removes all of the tumor, but it can be hard to tell where a tumor ends and healthy tissue begins. Surgical resection of cancerous tissues is a critical procedure for solid tumor treatment. During the operation, the surgeon mostly identifies the cancerous tissues by naked-eye visualization under white light without aid. The outcome heavily relies on the surgeon’s experience. According to an article published on September 22, 2021 in the American Chemical Society’s journal ACS Sensors, a near-infrared pH-responsive fluorogenic dye, CypH-11, was designed to be used as a sensitive cancer spray to highlight cancerous tissues during surgical operations, minimizing the surgeon’s subjective judgment. This fast-acting spray could be a handy and effective tool for fluorescence-guided surgery, identifying small cancerous lesions in real time for optimal resection without systemic toxicity.

Acupuncture In The Ear To Reduce Pain And Opioid Use For Total Knee Replacement Surgery Patients

Patients who have acupuncture during total knee replacement surgery report less pain and need far fewer opioids to manage their discomfort, according to a study presented in October 2021 in San Diego, CA at the annual conference of the American Society Of Anesthesiologists. Results of the study, which occurred in New York City at the Hospital for Special Surgery, showed that 65% of patients who received acupuncture during surgery achieved a low-dose or opioid-free postoperative experience, compared to 9% of patients outside of the study. All patients received the institution’s standard opioid-sparing multimodal analgesic protocol, with the addition of electroacupuncture, a modified form of traditional acupuncture that applies a small electric current to thin needles that are inserted at known acupuncture points on the body. The acupuncture in this investigation was administered during surgery by a physician who is board-certified in medical acupuncture to eight specific points in the ear to provide targeted pain relief in the knee.

DEVELOPMENTS IN HIGHER EDUCATION

Each edition of this newsletter issued by the Association of Schools Advancing Health Professions (ASAHP) provides information about the two domains of health care and education that are separate from one another in many important respects, but also closely related. The steady aging of the U.S. population is accompanied by increases in the number of patients in the oldest brackets who have co-morbidities. Addressing their health and social-related needs will require an adequate supply of competent, adequately prepared practitioners across a wide range of health professions. The education sphere is keenly involved in the production of teachers, clinicians, and researchers necessary to achieve optimal results. Although a main focus is on what transpires in colleges and universities, other levels involving elementary and high schools play a significant role in determining which students will arrive at the door of health professions academic institutions and be able to thrive in that setting once admitted.

The following discussion looks at some key variables involving the ability of students and their families to pay for that level of education and preparation necessary to begin a career in the health professions; the quality of education at levels below college; and the ability to complete formal education in a reasonable time period. Concerning the latter point, race and ethnicity have a bearing on how long it takes students to complete four-year degree programs. A Digest of Education Statistics from the National Center for Education Statistics has data showing that fewer than 50% of students at four-year colleges graduate within four years, which means that longer periods of time can not only produce higher costs than originally expected, but also delay the start of a career. Significantly, non-white students tend to be more burdened with such problems than what white students experience.

Meeting The Costs Associated With Participating In Higher Education

Tuition and related fees pertaining to functions involving meals and residence on campus are beyond the reach of many families. Depending on the amount of time spent in school and the type of education required to become a health professional, some students will graduate with a debt that may exceed $100,000 (e.g., physicians). The current average is approaching $40,000. At the time of distribution of this issue of the newsletter, the fate of $3.5 trillion social spending legislation in Congress has not been determined yet. One component entails making two years of community college free for all and a related piece is increasing the largest Pell Grant awarded to low-income students by $500. Entrance into some health professions requires only an associate degree. Participation in other professions make it necessary to achieve baccalaureate or even higher degrees. Many students who begin at the community college level manage to have credits transferred to four-year institutions and save money in the process of doing so. Also, nearly a third of students skipped the Free Application from Federal Student Aid or FAFSA® last year, with the form’s complexity posing a major reason why they did so. A step in the right direction is that the consumer banking company Sallie Mae launched a free suite of financial education instruments and planning resources, including a FAFSA support tool that can help families complete the form in minutes, to help students maximize federal financial aid.

Quality Of Education Below The College Level

Many students around the nation are plagued by having to attend public schools where dismally low percentages of youth are able to come even close to achieving proficiency at particular grade levels (4th and 8th grades) in reading, mathematics, and science. Alternatives exist in the form of charter schools and voucher programs that enable low-income parents to meet tuition costs in private institutions. Depending on the political jurisdiction at federal, state, county, and city levels, these options may be resisted fiercely. Regarding the issue of charter schools, according to data collected and analyzed by the National Alliance for Public Charter Schools, during the first full school year of the COVID pandemic, a report released in September 2021 shows that the charter sector is likely to have experienced the largest rate of increase in student enrollment in half a decade. Public charter school enrollment increased during the 2020-2021 school year in at least 39 states, the only segment of the public education sector to grow during the COVID-19 pandemic, according to the data compiled by the National Alliance. All told, nearly 240,000 new students enrolled in charter schools during that period, a 7% year-over-year increase, which likely represents more than double the rate of growth from the prior year.

HEALTH REFORM DEVELOPMENTS

The health sector in the U.S. represents approximately 18% of the world’s largest economy. Given the steady numerical and proportional increase in the number of individuals in this nation who are age 65 and older, many of whom have co-morbidities that are costly to treat, that 18% figure can be expected to continue to inch higher. A complaint issued at regular intervals over the decades is that the health sector consists of too many silos that function independently of one another. An area in which improvements have been made, however, involves interprofessional education and clinical care. The Association of Schools Advancing Health Professions (ASAHP), the proprietor of this newsletter, has played an active role in fostering interprofessional improvements and innovations.

Apart from the silo aspect that characterizes portions of the health sphere, it is worth considering that the health domain is just one of several major silos (e.g., agriculture, housing, and national defense) in the overall economy. These other entities bear directly and indirectly on what transpires in the health area. The cost and availability of healthy foods has a role to play in enhancing individual and community health status. The quality of the housing stock and where it is located in every community around the nation have an impact on health. High rental costs, ability to obtain loans to purchase homes, and the extent of crime in neighborhoods are factors that influence personal health. A defense system capable of detecting and preventing biological warfare launched by other nations is necessary to ward off a threat of future pandemics. From the framework of this larger perspective, listed below are some ingredients of the overall U.S. economy that can influence events that unfold in the health domain.

U.S. Census Bureau Data On Income, Poverty, And Health Insurance

The U.S. Census Bureau announced on September 14, 2021 that median household income was $67,521 in 2020, a decrease of 2.9% from the 2019 median of $69,560. The drop is the first statistically significant decline in median household income since 2011. The total number of individuals with earnings decreased by about 3.0 million, while the number of full-time, year-round workers decreased by approximately 13.7 million. The official poverty rate in 2020 was 11.4%, up 1.0 percentage point from 2019, which is the first increase in poverty after five consecutive annual declines. In 2020, there were 37.2 million individuals in poverty, approximately 3.3 million more than in 2019. Private health insurance coverage continued to be more prevalent than public coverage, at 66.5% and 34.8%, respectively. Some beneficiaries may have more than one type of coverage during the calendar year. Of the subtypes of health insurance, employment-based insurance was the most common variety, covering 54.4% of the population for some or all of the calendar year.

Employment represents the main source of income for a great many inhabitants of the United States. A recurring fear is that the COVID-19 pandemic has resulted in the permanent elimination of many different kinds of jobs. Depending on an individual’s level of education and job skills, it may be possible to obtain new employment in totally different sectors of the economy, but what happens to everyone who is not so fortunate? Even when public assistance is available, will the newly unemployed be able to obtain the same quality of health care from the same providers they relied upon in the past? Declines in household income can affect the ability to meet out-of-pocket health care expenses for necessary purchases, such as for pharmaceuticals. Although not considered a tax, recent increases in inflation that have occurred in 2021 have led to a dramatic rise in the cost of fuel for motor vehicles. Food costs also have been soaring in recent months. Placing food on the table and filling gasoline tanks needed to commute to the workplace are unavoidable expenses that have the potential to crowd out other necessities, such as health care.

U.S. Health Insurance Market Competition

Seventy-three percent of U.S. commercial health insurance markets are highly concentrated based on guidelines used by the Department of Justice and Federal Trade Commission to assess market competition, according to the latest annual report on health insurance competition by the American Medical Association. In 91% of the 384 metropolitan statistical areas studied, at least one insurer had a commercial market share of 30% or more, and in 46% of MSAs a single insurer’s share was at least 50%. Fifty-four percent of markets that were highly concentrated in 2014 became even more concentrated by 2020. A concern is that these markets are ripe for the exercise of health insurer market power, which harms consumers and providers of care.

FEDERAL BUDGET INITIATIVES AT LOGGERHEADS

As the month of September drew to a close and October began, efforts continued on Capitol Hill to reach agreement on two key pieces of legislation: (1) an infrastructure bill, and (2) a separate social policy and climate bill. A bipartisan group of 69 senators, all 50 Democrats and 19 Republicans, in August 2021 successfully passed a roughly $1 trillion infrastructure package aimed at improving the nation’s roads, bridges, ports, and also expanding broadband Internet access for the population. For example, the current provision of telehealth services to residents of rural areas is hampered by broadband being too narrow. The larger bill has a much bigger price tag and is proving to be more nettlesome from the standpoint of not only its broad aims, but also whether it should be passed separately or at the same time as infrastructure legislation.

Disagreements are of both an inter-party nature between Democrats and Republicans as well as between competing factions in the Democratic party. The desired amount of spending for a social policy bill that has a focus on expanding Medicare to include vision, hearing, and dental care; universal prekindergarten; two free years of community college; and creation of a program encouraging utilities to reduce carbon emissions is $3.5 trillion. That figure is where Republicans part company with the Democrats, indicating that several initiatives not only are wasteful, but even have the potential through proposed tax increases to do substantial harm to the overall economy. Within the Democratic party, conflicts also exist between progressives who favor the $3.5 trillion package and centrists who believe that the projected amount of spending is too high and who also have concerns about the amount of taxation needed to finance proposed undertakings.

Adding to the complexity of the situation is the composition of Congress. Usually, Democrats cannot afford a single defection in a Senate that is evenly split between Democrats and Republicans. Whereas over on the House side of Capitol Hill, a thin majority of Democrats means that a loss of a mere three votes can sink what they hope to achieve. The Senate is of much less concern because of the availability of a process called reconciliation, which could make it possible to approve the social policy and climate bill. Rather than needing 60 votes to achieve passage, a simple majority is all that is necessary. Timing also plays an important role. Progressives have indicated that they will block the infrastructure bill if it arrives on the floor for a vote before agreement has been reached on the proposed $3.5 trillion bill.

Other remedies continue to be recommended. One example is to include more short-term spending in the domestic policy package, which would reduce the overall size of the legislation without having to choose which cuts to make, an option that would allow the possibility of extending programs into the future. A different approach would be to fund a reduced number of programs for the long-term rather than expecting to have enough votes in the future when programs might be cancelled. Also, Senator Bernie Sanders (I-VT) has suggested that Medicare benefit expansion should be accompanied by $1,000 debit cards for individuals based on low-income to access vision, hearing, and dental services earlier than what would be provided by the reconciliation bill (e.g., vision in 2022, hearing in 2023, and dental in 2028).

NEUROBIOLOGY OF LONELINESS

The human heart in conflict with itself and the loneliness of the soul have served as inspiration for various forms of artistic expression throughout the ages. Regarding the latter condition, in popular music a top song in 1969 by the group Three Dog Night was titled, “One Is The Loneliest Number.” That particular numeral posits that an aspect of loneliness is a subjective feeling of being isolated and alone. In a related vein, social isolation is an objective state of having few relationships or infrequent contact with others. Meanwhile, along with many other nations, the United States is undergoing a profound demographic shift in which the size of the population 65 years of age and older, both numerically and proportionately, is increasing at a more accelerated rate than it is for younger age groups.

The National Academies of Science, Engineering, and Medicine published a report in 2020 on social isolation and loneliness among older adults, indicating that approximately 24% of community-dwelling Americans aged 65 and older are considered to be socially isolated. A significant proportion of adults in this country report feeling lonely, that is, 35% aged 45 and older and 43% aged 60 and older. Current evidence suggests that many older adults are socially isolated or lonely (or both) in ways that place their health at risk. Moreover, social isolation significantly increases an individual’s risk of mortality from all causes, a risk that may rival the risks of smoking, obesity, and lack of suitable physical activity. Additionally, loneliness has been associated with higher rates of clinically significant depression, anxiety, suicidal ideation, a 59% increased risk of functional decline, and a 45% increased risk of death. Poor social relationships (characterized by social isolation or loneliness) also have been associated with a 29% increased risk of incident coronary heart disease and a 32% increased risk of stroke.

While acknowledging that loneliness is associated with increased morbidity and mortality, an article published in the October 2021 issue of the journal Neuropsychopharmacology indicates that a deeper understanding of the neurobiological mechanisms that underly loneliness is needed to identify potential intervention targets. Identifying such mechanisms is critical for understanding how loneliness contributes to poor mental and physical health, and for conceptualizing potential pharmacological and neurostimulation targets. This first systemic review of the neurobiology of loneliness shows that despite some mixed evidence, the condition is associated with structural and functional differences in the prefrontal cortex, insula, hippocampus, amygdala, and posterior superior temporal cortex, as well as attentional and visual networks.

Apart from the impact on patients, loneliness also can have a major effect on the health care delivery system as measured by an increased use of inpatient care, more visits to providers, increased re-hospitalizations, and longer lengths of stay. A challenge for providers is to develop effective methods to identify social isolation and loneliness in health care settings and use the findings to target appropriate clinical and public health interventions to individual patients, and to target high-need regions and populations served by a practice or health care system.

HOW JUDGMENTAL OR OFFENSIVE WORDS IN OUTPATIENT NOTES MATTER

Health systems increasingly are offering patients ready electronic access to clinician notes and patients strongly support such practice, citing many potentially important clinical benefits. Allowing patients a window into how clinicians view them and their conditions, however, such notes also may cause patients to feel judged or offended, and thereby reduce trust. A study described in the September 2021 issue of the Journal of General Internal Medicine involved data collected from 22,959 patient respondents in three health systems: Beth Israel Deaconess Medical Center in the Boston area, University of Washington Medicine in Seattle, and Geisinger, a rural integrated health system in Pennsylvania to determine what patients may find judgmental or offensive in their notes.

A thematic analysis had a focus on the following domains: Errors and Surprises, involving descriptions of finding inaccuracies in the record and instances when the note negatively surprised the patient. For example, patients reported feeling judged/offended due to documentation of physical examinations or discussions that the patient believed had not occurred. Labeling, which entailed patients reported feeling judgment/offense when they felt they were labeled by clinicians. Descriptions of obesity were a frequent cause of feeling negatively labeled, as were other personal descriptors such as “elderly,” ”anxious,” “well-groomed,” or descriptions of patients’ emotional demeanor. Disrespect, with some patients feeling disrespected when they perceived their perspective was not recorded, misunderstood, represented incorrectly, or not valued. Among the patient respondents who had read at least one note and answered two questions, 2,411 (10.5%) reported feeling judged and/or offended by something they had read. Individuals who reported poor health, unemployment, or inability to work were more likely to feel judged or offended. Among those patients, 2,137 (84.5%) wrote about what prompted their feelings. Conclusions reached in the study are that content and tone may be particularly important to patients in poor health. Enhanced clinician awareness of the patient perspective may promote an improved health care lexicon, reduce the transmission of bias to other clinicians, and reinforce healing.

FACETS OF HEALTH AND PERSONALIZED PROFILES FOR DISEASE RISK

Providing the best possible care for an individual means possessing a better understanding of the risks of developing disease. The goal is to have personalized answers when individuals need to know whether, for instance, preventive surgery makes sense, a given medicine is likely to be risky, or a certain diet should be recommended. According to an article in the September 9, 2021 issue of the journal Nature, information on genetic risk represents one promising approach to providing these answers. Genomic data, gathered across millions of individuals, have revealed thousands of DNA sequence variants associated with common diseases such as diabetes, heart disease, schizophrenia, and cancer. These clues to disease risk can be combined to generate ‘polygenic scores’ that provide a measure of the degree to which an individual genetically is predisposed to developing each such disease. A growing chorus of scientists and clinicians emphasize the value of such genetic profiling as an integral part of a personal medical record.

Alternatively, others argue that the clinical benefits have been massively overstated. This debate often fails to recognize that the challenge is not merely to improve understanding of genetic risk, but to capture more about the interwoven, multifaceted factors that play into disease risk. Perhaps a more pertinent argument would be that clinical medicine must learn to develop more-holistic measures of individual risk, both genetic and non-genetic, and to combine these with clinical data over time to deliver better care. Although current polygenic scores hold clinical promise, they come with several limitations. They leave out many sources of relevant data, and work best for the predominantly white, wealthy populations in which most genetic studies have been performed. The emphasis on genetic risk diverts attention away from non-genetic factors that might be equally important for disease risk and progression. Risk estimation on the basis of polygenic scores alone also fails to incorporate real-time measurements of clinical state that are especially important in diseases linked to aging. As a way of moving forward, researchers, funders, and industry need to embrace greater diversity in the design and implementation of studies, focusing not only on gender and ethnicity, but also on social, cultural, and economic factors that influence disease risk and access to health care.

OBTAINABLE RESOURCES

Population Health In Challenging Times

The year 2020 presented extraordinary challenges to organizations working to improve population health. As a means of understanding how various domains in the population health field are responding to and being changed by two major crises (racial injustice and the COVID-19 pandemic), the Roundtable on Population Health Improvement of the National Academies of Sciences, Engineering, and Medicine held a workshop on September 21-24, 2020, titled Population Health in Challenging Times: Insights from Key Domains. The workshop had sessions organized by themes, such as academic public health and population health; health care; and governmental public health. Each panel discussion highlighted difficulties and opportunities, both internal to the respective institutions and sectors, and at the interface with peers and partners, especially communities. A publication that summarizes the presentations and panel discussions from the workshop can be obtained here.

New Platforms Of Health Care

For the past century, health care measurement and delivery have been centered in hospitals and clinics. That arrangement is beginning to change as health measures and increasingly care delivery are migrating to homes and mobile devices. The COVID-19 pandemic has only accelerated this transition. While increasing access to care and improving convenience, this move toward platforms operated by for-profit firms raises concerns about privacy, equity, and duty that will have to be addressed. Also, this change in measuring health and delivering health care will create opportunities for educators to expand the settings for training, researchers to conduct studies at enormous scale, payors to embrace lower-cost clinical settings, and patients to make their voices heard. An article published on July 15, 2021 in npj Digital Medicine can be obtained here.

Geriatric Emergency Department Accreditation Program In The United States

Rapid growth in geriatric emergency departments (EDs) has been driven by Level 3 accreditation. Most geriatric EDs are in urban areas, indicating the potential need for expansion beyond those locations. Future research evaluating the impact of GEDA on health care utilization and patient-oriented outcomes is needed. The results of a recent study were published on August 10, 2021 in the journal Annals of Emergency Medicine. The objectives of this research were to describe the reach and adoption of Geriatric Emergency Department Accreditation (GEDA) program and care processes instituted at accredited geriatric emergency departments (EDs). Investigators analyzed a cross-section of a cohort of 225 EDs in the U.S. that received GEDA from May 2018 to March 2021. Only nine geriatric EDs were in rural regions. Significant heterogeneity existed in protocols enacted at geriatric EDs; minimizing urinary catheter use and fall prevention were the most common. The article can be obtained here.

Financial Impact of COVID-19 On Older Adults

A survey conducted by the Commonwealth Fund between March and June 2021 reveals that nearly one in five older Americans, particularly older Black and Latino/Hispanic Americans, indicate that they used up their savings or lost their main source of income because of the COVID-19 pandemic, a rate several times higher than in other high-income countries. The results of the study can be obtained here.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Top Global Causes Of Adolescent Mortality And Morbidity, 2019

According to an Infographic that was published in the October 2021 issue of the Journal of Adolescent Health, the causes of mortality among adolescents are different than the causes of morbidity. Injuries such as road injury, drowning, and self-harm; communicable diseases including diarrheal diseases, tuberculosis, and lower respiratory infections; and maternal conditions are the main causes of mortality among adolescents. Road injury is the leading cause of mortality among adolescent boys. Mental disorders including childhood behavioral, anxiety, and depressive disorders are among the leading causes of morbidity among adolescents of both sexes and across age groups. Iron-deficiency anemia is an important cause of morbidity among younger adolescents of both sexes. Another paper in that issue discusses how adverse health-related outcomes such as greater substance use, mental health difficulties, and higher BMI appear to be more likely to cluster together in the more recent cohort, with public health implications.

Adult Day Services Center Participant Characteristics: U.S., 2018

A Data Brief published on September 2, 2021 by the National Center for Health Statistics indicates that an estimated 251,100 participants were enrolled in adult day services centers (ADSCs) in the United States in 2018. Compared with users of other long-term care services, ADSC participants were younger and more racially and ethnically diverse. ADSC participants have a diverse set of needs, with many of them requiring assistance with activities of daily living (ADLs) and having chronic health conditions. About 57% of adult day services center (ADSC) participants were female, 45% were non-Hispanic white, and 39% were under age 65. Most ADSC participants were Medicaid beneficiaries (72%) while about 85% of participants under age 65 were Medicaid beneficiaries. About 64% of participants needed assistance with three or more activities of daily living. Most ADSC participants had two or three chronic conditions. Just over one-half of participants were diagnosed with high blood pressure.

HEALTH TECHNOLOGY CORNER

Persistence Of COVID-19 After Mild Infection

Uncertainty exists whether mild COVID-19 confers immunity to reinfection and questions also remain about the persistence of antibodies against SARS-CoV-2 after mild infection. A study published in the September/October 2021 issue of the journal Microbiology Spectrum reveals that approximately 90% of participants produced spike and nucleocapsid antibody responses, and all but one had persistent antibody levels at follow up. University of Michigan researchers analyzed nearly 129 subjects with PCR-confirmed COVID-19 illness between three and six months after initial infection. The prospective study’s participants either were Michigan Medicine health care workers or patients with a high risk of exposure to COVID-19. The results show that individuals who have mild COVID-19 illnesses and produce antibodies are protected from reinfection for up to six months afterward. Reinfection was not observed among individuals with mild clinical COVID-19, while infections continued in a group without known prior infection.

Shared Movement Disorders Walking Patterns Among Different Species

Neurodegenerative disorders including Parkinson’s disease, Alzheimer’s disease, and schizophrenia are conditions characterized by motor dysfunctions. Since the variables inherent to such diseases cannot be controlled directly in humans, behavioral dysfunctions and their neural underpinnings have been examined in model organisms. An article published on September 17, 2017 in Nature Communications describes how machine learning was used to obtain patterns from locomotion data created by worm, beetle, mouse, and human subjects that were independent of the species. Researchers at Osaka University trained a deep learning algorithm and used animal location tracking along with artificial intelligence to detect walking behaviors of movement disorders that are shared across species. By automatically removing species-specific features from walking data, the resulting information can be used to understand neurological disorders better, such as Parkinson’s disease that affect movement.

DEVELOPMENTS IN HIGHER EDUCATION

The U.S. Census Bureau announced on September 14, 2021 that median household income in 2020 decreased 2.9% between 2019 and 2020, and the official poverty rate increased 1.0 percentage point. Median household income was $67,521 in 2020, a decrease from the 2019 median of $69,560, making it the first statistically significant decline in median household income since 2011. Between 2019 and 2020, the real median earnings of all workers decreased by 1.2%, while the total number of individuals with earnings decreased by about 3.0 million and the number of full-time, year-round workers decreased by approximately 13.7 million. The official poverty rate in 2020 was 11.4%, up 1.0 percentage point from 2019, marking the first increase in poverty after five consecutive annual declines. In 2020, there were 37.2 million individuals in poverty, approximately 3.3 million more than in 2019.

This deteriorating income picture has enormous implications for students who wish to attend higher education institutions. During the 1950s and 1960s, for example, a great many students achieved a college education as commuters who lived at home and traveled to the campus each day by subway, bus, and carpool. Along with their books, they brought a lunch in a brown bag along with them. During the school year, they might have worked at supermarket checkout counters on the weekends and do the same or find other low paying employment in the summertime. The net result was that they could earn enough to cover tuition costs. Clearly, those days are gone forever and have been replaced by the accumulation of substantial amounts of student debt upon completion of community college and baccalaureate degrees. Unless conditions substantially are modified, the dream of attaining such degrees increasingly will be further out of reach for many individuals. This distressing prospect occurs at a time when the possession of a degree is associated more than ever with the likelihood of earning a decent salary.

Runaway Spending In Higher Education Institutions

A new report from the American Council of Trustees and Alumni points out that an onerous debt burden currently has reached an average of $39,351 for the 65% of students who borrow money to fund their college education. That face changes from grim to tragic for the 6% whose burden is greater than $100,000. Rationalizations for this economic catastrophe are viewed as ringing hollow. College debt does not comport with the dismissive description, “good debt,” once so popular among higher education administrators. High levels of student loan debt have been shown to postpone major life events dramatically, with borrowers reporting delays in saving for retirement (62%), buying a home (55%), marriage (21%), and starting a family (28%).

The Council does not envision debt forgiveness as a meaningful solution because it merely is a way of shifting the burden to the American taxpayer. More importantly, debt cancellation is but a temporary remedy that treats the symptom and not the disease. How, exactly, did the cost to attend college in the United States rise so high? A parallel consideration is that investment in instructional staff, particularly tenured or tenure-track professors, has been overshadowed by increases in administrative staff, namely well-paid, professional employees. A proposition is advanced that even the most optimistic would be hard-pressed to argue that colleges today are providing nearly three times the educational value that they did 30 years ago, which would otherwise justify the 178% increase in sticker price at four-year public institutions since 1990. This argument crumbles in the face of studies that show that one-third of students leave college without any growth in critical thinking or analytical reasoning skills and that only 49% of employers think recent graduates are proficient in oral and written communication.

The report illustrates the implications for students, both financially and academically, of the steady growth in spending since the Great Recession. It is hoped that public awareness of this trend’s impact on student finances and student outcomes will encourage more prudent choices. A proper understanding of an institution’s spending habits can provide valuable insights for governing boards seeking to allocate scarce resources efficiently toward what most benefits students.

HEALTH REFORM DEVELOPMENTS

The Patient Protection and Affordable Care Act became law in March 2010. Since then, it has been characterized by rulings issued from the offices of state attorneys general, appellate courts, and the U.S. Supreme Court, along with executive orders promulgated by the nation’s presidents and additional guidance provided by the Department of Health and Human Services in Washington, DC. It is conceivable that efforts to stay abreast of this ever growing cascade of information would tax even the energies of the most highly gifted Talmudic scholars were they ever to shift their attention in that non-heavenly direction.

Fortunately or not, there is a veritable army of interest groups represented in the nation’s capital to maintain a close watch on all imaginable health policy developments to ensure that every T is crossed and every I is dotted correctly. As an aside, it may not be hyperbolic to assert that every major piece of legislation in both the health and education realms just as easily could be subtitled the Attorneys, Accountants, and Lobbyists Relief Act of (fill in the appropriate year) since practitioners of those trades essentially are furnished with lifetime employment opportunities once enactment occurs.

One example of how muddles can bring matters to a halt can be traced to the mid-1970s. The services of physician assistants and advance nurse practitioners were unable to be reimbursed by Medicare unless a physician was present to observe and approve what they were doing. Unfortunately, rural areas of the U.S. are geographically vast in size and also characterized by physician workforce shortages. A bill was introduced in Congress to remedy the situation by indicating that a physician did not have to be physically present when services were being provided. All was proceeding swimmingly until a bill was produced with language that referred to these other personnel as physician extenders. Opposition was fierce because representatives of other professions viewed themselves as being independent qualified operators rather than mere extensions of physicians. It subsequently took more than an extra year to resolve that predicament in order to have the bill enacted. Welcome to the ways of Washington, DC.

Cost Effects Insurance Reforms Being Considered By Congress

Plans are being formulated on Capitol Hill to make permanent the American Rescue Plan Act’s temporary boost in subsidies for marketplace plans and to fill what is known as the Medicaid coverage gap. As part of the budget process for fiscal year 2022, which begins on October 1 this year, Congress is considering a package of two reforms to the Affordable Care Act (ACA). Under what is being developed, the enhanced premium subsidies included in the American Rescue Plan Act would become permanent. Also, the so-called Medicaid coverage gap would be filled by extending eligibility for marketplace subsidies to individuals earning below 100% of the federal poverty level in 12 states that have not yet expanded Medicaid.

Presently, there are about 5.8 million uninsured adults in those states that have incomes too high for that program, but not high enough to obtain marketplace subsidies. Together, these two health insurance reforms would sharply reduce the number of Americans under age 65 who lack coverage, according to a new analysis from the Urban Institute and the Commonwealth Fund. Not only would Black Americans see the biggest decline in the ranks of the uninsured, but uninsured numbers for white and Latinx/Hispanic adults also would fall significantly as well. Researchers project the changes would result in lower financial burdens for households struggling with health care costs.

Improving Health Care For The Nation’s Older Veterans

An announcement on September 9, 2021 from the Department of Veterans Affairs (VA) describes the launching of a nationwide movement to improve emergency department (ED) care for older veterans treated in VA Medical Centers and become the nation’s largest integrated health network with specialized geriatric emergency care. The VA Geriatric Emergency Department Initiative is a public-private collaboration between the VA, the American College of Emergency Physicians (ACEP), The John A. Hartford Foundation, and the West Health Institute to establish 70 of the VA’s EDs as accredited geriatric emergency departments (GEDs). These entities are better equipped to treat older adults with complex conditions while recent studies have found that GEDs can decrease hospital admissions and lower total healthcare costs.

BUDGET RECONCILIATION ON A MASSIVE SCALE

A key approach to achieve legislative objectives would be to use budget reconciliation procedures to pass some tax and spending measures in areas, such as Affordable Care Act enhancement and pandemic relief. 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, the late 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 22 reconciliation measures from late 1985 through the present.

During the month of September this year, various committees of jurisdiction in the House of Representatives have been working to advance major components of a $3.5 trillion reconciliation package. Examples include the following:

Education and Labor Committee

This group has been focusing on its portion of the Build Back Better plan, tuition assistance for community college students, increased funding for the Pell Grant program, and significant new investments in historically black colleges and universities, and other minority serving institutions.

Energy and Commerce Committee

Its members seek to address the “Medicaid coverage gap” and permanently extend the Children’s Health Insurance Program; allow the Medicare program to negotiate the prices of certain medications; invest in public health infrastructure and the health workforce; and fund pandemic preparedness efforts.

Ways and Means Committee

Constituents of this legislative body are considering medical education and other workforce issues; extending the expanded Affordable Care Act Marketplace premium tax credits from this year’s COVID-19 legislation; addressing drug pricing; and expanding Medicare benefits for dental, vision, and hearing.

Budget Committee

Participants involved in the activities of this entity ultimately will combine the health care measures with various education, housing, climate, and transportation provisions.

Apart from what occurs in the House, a Senate that lacks a majority by either of the two major political parties means that Democrats must be unified in their support. Although that party enjoys a majority in the House, the margin is slim. Thus, it will take only a small handful of Democrats to prevent the bill from being passed once it arrives on the House floor. If it does make its way to President Biden for his signature into law, it will be the most significant legislation of its kind since the New Deal in the 1930s.

BIOLOGICAL TECHNOLOGY PROSPECTS

Developments in the realms of science and technology continue to produce advances that not only are exciting, but also potentially frightening. Promising and controversial biological technology has included cloning, embryonic stem cells, and in vitro fertilization. More recently is the addition of CRISPR (clustered regularly interspaced short palindromic repeats), a tool for editing humans.

From the standpoint of achieving widespread public visibility, part of the story begins with the first publication of the idea of CRISPR in June 27, 2012 online in the journal Science by Jennifer Doudna of UC Berkeley and Emmanuelle Charpentier, a researcher born in France who was a faculty member at Umëa University in Sweden. They eventually were awarded the Nobel Prize in Chemistry in 2020. Shocking reactions occurred around the world in November 2018 when it was learned that two babies had been born in China with DNA edited while they were embryos, a development in genetics as dramatic as the 1996 cloning of Dolly the sheep. The two babies, nonidentical twin girls, were the first CRISPR’d individuals ever born as a result of experimentation by He Jiankui who claimed to have overseen the use of CRISPR to modify a gene in the human embryo called CCR5, a gene known to be important in allowing HIV to infect some human cells.

Readers with an interest in this topic may find it worthwhile to obtain a copy of a book that recently became available. It has the title, “CRISPR People: The Science and Ethics of Editing Humans” and it was written by Henry T. Greely, Professor of Law and Director of the Stanford Center for Law and the Biosciences at Stanford University. This author provides useful background information to the He Jiankui announcement and how CRISPR was used by that researcher.

Human germline genome editing and CRISPR are explained in this publication, along with a description of ethical discussions about and the legal status of such editing. Three chapters detail the revelation of Jiankui’s experiment and the fallout from those revelations. Part III of the text deals with assessments, while Part IV asks more broadly about human germline genome editing. For example, Professor Greely does not pull any punches by judging the experiment involving the two babies as criminally reckless, grossly premature, and deeply unethical.

One editing possibility involves enhancement, i.e., not for enhanced protection against diseases, but for producing better than normal traits or abilities for athletics, education, music, personal beauty, and other prized attributes. Focusing on that kind of intervention may not be the most beneficial way for CRISPR technology to proceed. Instead, somewhere between treating disease and enhancing traits would be to edit disease-prevention genetic variations into an individual’s genome. Rather than editing out an unusual pathogenic variation in favor of a common variant, the procedure could be used to edit out a common, normal-risk variant and turn it into an uncommon (or even) rare variation that lowers the risk below the population average. The author also notes that the real problems with introducing disease-prevention variations to a genome are not with the process, but with the result.

INCONSISTENT COMMUNICATION ABOUT COVID-19 VACCINES

According to a manuscript published in the July 2021 issue of the Journal of Communication in Healthcare, inconsistent communication about COVID-19 from public officials has created mistrust and confusion about public health recommendations, which has contributed to increased mortality in the United States. National, state, and local leaders have offered conflicting narratives about the seriousness of the pandemic, the steps needed to contain it, and the safety of the vaccines that are being administered. Much conflict has been over the choice of public health safety or the need to keep businesses and schools open. Framing this binary choice between public safety and the economy may be presenting a false dichotomy since containing the spread of COVID-19 is a prerequisite for a strong economy and a return to normal activities.

Language is viewed as playing an important role in the likelihood of motivating individuals to follow science-based public health recommendations and feel more confident about taking a COVID-19 vaccine. By a margin of 61% to 39%, one poll showed that respondents said the benefits of taking the vaccine would be more likely to motivate them than the consequences of not taking it. Moreover, gaining trust is particularly vital when communicating with members of vulnerable, marginalized, and underserved communities who regularly face systemic barriers and discrimination. Polling also examined differences in words that are likely to build trust about COVID-19 vaccines among Black and Latinx respondents. Overall, when these individuals were asked to choose the words that would give them the most trust and confidence in the COVID-19 vaccine (from a list of 12), the two most popular words were “advanced” and “groundbreaking.” Among Black respondents, however, the most preferred word was “innovative,” and for Latinx respondents, “unprecedented” was the first choice.

LANGUAGE CHOICE IN REDUCING STIGMA AROUND HEALTH CONDITIONS

Words used to describe mental illnesses and substance use disorders (addiction to alcohol and other legal and illegal drugs) can have an impact on the likelihood that individuals will seek help and the quality of the care they receive. Stigma, i.e., negative attitudes toward persons based on distinguishing characteristics may contribute in multiple ways to poorer health outcomes. An article published on July 19, 2021 in the journal Neuropsychopharmacology indicates that researchers and clinicians can help reduce stigma by carefully choosing the words they use to describe mental health conditions and addictions and the patients who are affected by them. Mental illnesses and substance use disorders always have been among the most stigmatized of health conditions. Because language can shape thoughts and beliefs, scientific communication sometimes may serve as an inadvertent vector of harmful stereotypes and assumptions.

A concern is that bias among medical professionals and mental health service providers can reduce the likelihood that individuals with mental illnesses will be offered or receive appropriate treatment or be referred for specialty care. Stigma against individuals with substance use disorders has proven particularly intractable. The public continues to see these disorders as character flaws or even as deviance, contributing to a treatment-averse mindset even among some physicians and health care providers. For example, some clinicians were more likely to favor punishment (a jail sentence) versus treatment for someone when that individual was described as a “substance abuser” versus having a “substance use disorder. Instead, using scientifically accurate language and terms that centralize the experience of patients who experience psychiatric conditions and that validate their worth can positively affect how they are treated within health care and in society more generally.

Similarly, the August 2021 issue of the journal The Gerontologist includes a paper discussing how in research Alzheimer’s Disease (AD) is referred to as a pathophysiological process, regardless of whether clinical symptoms are present, whereas in the lay literature, it is understood as a form of dementia. The two different uses of the term may result in misunderstandings, especially those research framings that falsely imply that patients with AD biomarkers inevitably will develop dementia. Adoption of the research understanding of AD in clinical practice will have normative implications, e.g., it legitimizes biomarker testing in individuals without dementia as improving “diagnostic” certainty.

OBTAINABLE RESOURCES

Federal Policy Priorities For The Direct Care Workforce

PHI has released a report entitled, "Federal Policy Priorities for the Direct Care Workforce." The document offers an extensive and detailed set of federal policy recommendations for that portion of the workforce. Throughout the United States, millions of direct care workers—home care workers, residential care aides, and nursing assistants—ensure that older adults and patients with disabilities have the support they need across care settings. The report proposes federal policy recommendations to strengthen the direct care workforce across eight issue areas: financing, compensation, training, workforce interventions, data collection, direct care worker leadership, equity, and the public narrative. The report also offers nearly 50 concrete recommendations for the White House, Congress, and key federal departments and agencies. It includes recommendations for navigating and learning from COVID-19. The report can be obtained here.

Reducing The Impact Of Dementia In The United States

The National Academies of Sciences, Engineering, and Medicine (NASEM) have released
a report detailing the path forward for the next 10 years of research on dementia in the behavioral and social sciences. The NASEM report recommends that research prioritize improving the lives of patients affected by dementia and of their caregivers; rectifying disparities; developing innovations that can improve quality of care and social supports; easing the economic costs of dementia; and pursuing advances in researchers’ ability to study the disease. The report also indicates that research will be most effective if it is coordinated to avoid redundant studies; ensures findings can be implemented in clinical and community settings; and takes policy and socio-economic implications into account throughout the course of a study. Funders of dementia-related research should incentivize these approaches and others in their guidelines for awarding research grants. The report can be obtained here.

The Future Of American Higher Education

The Director of the Georgetown University Center On Education And The Workforce offers his assessment of how the COVID crisis will result in long-term economic scarring of both individual students and postsecondary institutions in America. Viewed in the context of what might come next for postsecondary education, his sense is that COVID is just the beginning. As the pandemic subsides, it will open the way to demographic, economic, and policy changes that already were gaining momentum. He indicated that today’s postsecondary education and training system has become a new gearwheel, arguably the biggest gearwheel, in the American race and class inequality machine. The available evidence suggests that these two trends, the growing value of postsecondary education and its role in replicating race and class privilege, will continue and likely strengthen in the coming years. His views can be obtained here.

Can Health Organizations Improve Health Equity?

A report from the firm Deloitte addresses the question, “Can health care organizations move beyond lip service and take the steps needed to improve health equity?” The care patients receive and the outcomes they experience still can vary widely by race, age, income, ethnicity, gender, and even ZIP code. So, an issue worth exploring is whether health organizations can advance health equity. The report can be obtained here.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Provisional Life Expectancy Estimates For 2020

A report from the National Center for Health Statistics (NCHS) in July 2021 presents updated estimates of life expectancy based on provisional mortality data for the full year, January through December, 2020. Life expectancy at birth represents the average number of years a group of infants would live if they were to experience throughout life the age specific death rates prevailing during a specified period. In 2020, life expectancy at birth for the total U.S. population was 77.3 years, declining by 1.5 years from 78.8 in 2019. Life expectancy at birth for males was 74.5 years in 2020, representing a decline of 1.8 years from 76.3 years in 2019. For females, life expectancy declined to 80.2 years, decreasing 1.2 years from 81.4 years in 2019. The difference in life expectancy between the sexes was 5.7 years in 2020, increasing from 5.1 in 2019. Between 2000 and 2010, the difference in life expectancy between the sexes narrowed from 5.2 years to a low of 4.8 years and then gradually increased to 5.1 in 2019.

COVID-19’s Impact On Black Versus White Households

According to the results of a Pulse Household Survey released on July 21, 2021 by the U.S. Census Bureau, the coronavirus pandemic has produced higher rates of economic and mental health hardship for non- Hispanic Black adults (referred to as Black) than for non-Hispanic White adults (referred to as White) across several measures. Interpreting the results requires disentangling racial identity from other underlying conditions, such as poverty, lack of health insurance, and the greater likelihood in jobs where there is a higher risk of both infection and unemployment during the pandemic. The data suggest that the COVID-19 pandemic disproportionately affected Black households more adversely because the cumulative effects of job loss, food insufficiency, and financial insecurity resulted in uncertainty about how to pay for housing as well as more generalized anxiety. The fact that Black adults have been more likely than White adults to borrow money to make ends meet suggests that the pandemic’s impact may be prolonged as debts mount.

HEALTH TECHNOLOGY CORNER

Core Outcomes For Patients Living With Long COVID

A significant portion of patients diagnosed with COVID-19 subsequently experience lasting symptoms that include fatigue, breathlessness, and neurological complications months after the acute infection. Evidence for this condition is limited, however, and is based on small patient cohorts with short-term follow-up. An urgent need exists for the development of a core outcome set (COS) to optimize and standardize clinical data collection and reporting across studies and clinical practice. An international group of experts has developed a program of research with patient partners and the WHO called ISARIC (International Severe Acute Respiratory and emerging Infection Consortium) to develop a Post COVID-19 Condition COS. Post- COVID-19 Condition Core Outcomes will begin by surveying individuals living with the Post-COVID-19 condition, assess what outcomes matter, and build a plan in two phases. Phase One in 2021 will focus on what outcomes should be measured while Phase Two in 2022 will focus on how to measure these outcomes.

Longitudinal Association Of Total Tau Concentrations And Physical Activity With Cognitive Decline

Tau is a brain protein located in neurons and develops abnormally in individuals with Alzheimer disease. A study described on August 11 in JAMA Network Open describes an evaluation of the association of physical activity and total tau concentrations with cognitive decline at baseline and over time. Participants in the investigation are involved with the Chicago Health and Aging Project, a population-based cohort study conducted in four of that city’s communities. Study findings suggest that, among participants with both high and low total tau concentrations, physical activity was associated with slower cognitive decline. Results support the potential utility of blood biomarkers in measuring the benefits associated with health behaviors and may contribute to specifying target populations or informing interventions for trials that focus on improving physical activity behavior. A recommendation is that future work should examine the association of total tau concentrations with other health behaviors and physical activity types.

DEVELOPMENTS IN HIGHER EDUCATION

Approximately 23 million student-loan borrowers have benefited from a moratorium policy, which temporarily enables them to withhold making monthly payments on their federal debt load. Relating to the onset of the coronavirus pandemic, the pause on loan repayments and interest accrual went into effect on March 13, 2020 and was extended once to the end of that year. President Biden then extended it until September 30, 2021. In August, the moratorium was extended until January 31, 2022. It pertains to all loans held by the U.S. Department of Education, including Stafford, Grad PLUS, and consolidation loans. Some loans that originated under the Federal Family Education Loan (FFEL) are not eligible, however, since they are owned by private lenders.

Prior to these pauses, many students as a result of being unemployed or working in low paying jobs have found it impossible to pay their educational debts. Prominent Democrats have recommended using executive power to cancel as much as $50,000 of this debt for each borrower, while President Biden has indicated that it would be fair to do so in the amount of $10,000. Many congressional Republicans are less eager to provide such levels of relief. Depending on an individual’s status, debt has a differential impact on borrowers. One group of students who owe money consists partly of individuals who left school prior to completing degree programs. They are least likely to derive income from employment that enables them to pay back their loans. Another group is made up of students who might have debt as high as hundreds of thousands of dollars, but as graduates of post baccalaureate degree programs in medicine, law, and business, they are in a much stronger position to earn high paying salaries upon completing school.

Addressing The Educational Needs Of The Incarcerated

Individuals who enter penal institutions are not in an especially advantageous position to return to society upon being released from incarceration with a set of job skills in high demand by the employment sector. Instead, a further life of crime may be the only realistic way of producing income. Congress instituted a ban on the use of federal Pell Grants by incarcerated students in the Violent Crime Control and Law Enforcement Act of 1994 (P.L. 103-322). According to The Education Trust, the number of education programs in prisons subsequently dropped from more than 350 in 1990 to only a dozen in 2005. The percentage of incarcerated individuals participating in postsecondary education programs also dropped from 14% in 1991 to 7% in 2004.

The situation improved to some degree in December 2020 when Congress passed the Free Application for Federal Student Aid (FAFSA) Simplification Act, which reinstated prisoners’ access to Pell Grants. A next step is for the U.S. Department of Education to reverse Pell Grant restrictions. Otherwise, attainment of a college degree for prisoners remains challenging. The Education Trust indicates that correctional education programs reduce the rate of recidivism by 43%, increase the rate of employment after release by 13%, and are associated with fewer violent incidents in participating prisons. These programs are considered to result in net savings to taxpayers and are significantly more cost-efficient than incarceration alone. They also represent an essential strategy for breaking the cycles of incarceration and poverty, and helping formerly incarcerated individuals reintegrate into society.

New Negotiated Rulemaking Committee Meeting

The U.S. Department of Education on August 6, 2021 announced it will publish a notice in the Federal Register establishing a negotiated rulemaking committee that will meet virtually beginning in October of this year to rewrite regulations for Public Service Loan forgiveness, income-contingent repayment plans, and borrower defense to repayment, among other issues. These regulations will help borrowers manage repayment or receive a discharge or forgiveness of their federal student loans. The committee also will establish regulations to implement Pell Grant eligibility for incarcerated individuals, which will be discussed in a subcommittee. In the notice, the Department requests nominations for negotiators and sub- committee members and sets dates for negotiation sessions.

HEALTH REFORM DEVELOPMENTS

According to a new report from The Commonwealth Fund entitled, Mirror, Mirror 2021: Reflecting Poorly, the U.S. health system trails far behind its counterparts in 10 high-income peer countries when it comes to affordability, administrative efficiency, equity, and health care outcomes. Unique in measuring and comparing patient and clinician experiences across nations, the report shows that in the U.S., an individual’s chance of obtaining good health care depends to a large extent on income, more so than in any other wealthy country. The U.S., which spends the most per individual on health care, has ranked last in every edition of the report since 2004. Also, this nation has fallen even further behind on certain measures, especially health outcomes linked to primary care access and equity in care delivery.

Readers of this issue of ASAHP’s newsletter who have grown long in the tooth over the decades may recall a popular tune performed by Creedence Clearwater Revival in 1969 called Bad Moon Rising. Some of its lyrics are:

I see the bad moon a-rising
I see trouble on the way
I see earthquakes and lightnin'
I see bad times today

Oddly enough, despite the negative appraisal of health care in the U.S., this nation is distinguished by having world class centers that attract patients from all over the globe who seek the best in what these facilities have to offer. A major problem is that not all U.S. inhabitants are in a position to have equal access to such high quality care due to a factor, such as lack of adequate health insurance. Another relevant circumstance is what has been labeled “deaths of despair.” Angus Deaton and Anne Case at Princeton University have been successful highlighting a rise in mortality rates caused by inappropriate drug use, suicide, and alcoholic liver disease. They have noted that expected years lived between ages 25 and 75 declined for most of a decade for men and women without a four-year degree, even prior to the arrival of COVID-19. An article they wrote in the March 16, 2021 issue of the Proceedings of the National Academy of the Sciences in the USA discusses the link between possessing a college degree and the opportunity to obtain jobs that provide sufficient income. Ensuring the attainment of suitable levels of education, adequate employment prospects, decent housing, impact of discrimination, lack of necessary health resources in rural areas, and low crime neighborhoods are some multifactorial examples of the complex nature underlying efforts to improve individual and community health status.

State Initiatives To Improve Health Care

Because of its involvement in research funded by the National Institutes of Health, the financing of health services through Medicare, and the direct provision of such services through various government entities that include the Veterans Administration, the federal government rightly attracts significant attention when discussing health policy issues. Nonetheless, states around the nation also play key fundamental roles in attempts to foster a healthy population. Since taking office, the Biden administration has tried to enhance the Affordable Care Act (ACA) by reversing policies implemented when Donald Trump was President, such as the latter’s decision to eliminate a policy encouraging standardized health plan designs for marketplace coverage. Researchers at the Georgetown University Health Policy Institute believe that the federal government can learn from examining how states are using plan standardization to improve access to care. For example, cost barriers could be lowered by exempting critical primary care or mental health services from deductibles.

In a separate related arena, the Pew Charitable Trusts in its Legislative Review 2021, points out that local and state public health officials wield extraordinary powers in emergency situations, such as the present coronavirus outbreak. They can close schools and private businesses. They can restrict or shut down mass transit systems. They can cancel concerts, sporting events and political rallies. They can call up the National Guard when necessary. They can suspend medical licensing laws and protect physicians from liability claims. Not only can they quarantine or isolate some individuals who might infect others, they have the authority to implement policies that involve social distancing and the wearing of masks.