APPROPRIATIONS RICORSO

Each year, this newsletter serves as a vehicle for describing actions by Congress to appropriate funds that enable the federal government to continue its operations. A movie released in 1993 called “Groundhog Day” is about a television weather reporter who awakes each day and relives it repeatedly while he is in the town of Punxsutawney, PA to film a report about annual Groundhog Day festivities. A proposition is advanced that the appropriations cycle each fiscal year on Capitol Hill is somewhat reminiscent of that same situation.

Fiscal year 2022 began on October 1, 2021 with no permanent funding in place for the next 12 months. Short-term remedies had to be devised in the form of one or more continuing resolutions (CRs). The most recent one expired on February 18, 2022. Legislators had two choices. The most desirable option would be to pass an omnibus bill that encompass 12 different categories of spending. Otherwise, another short-term CR is needed to prevent the government from shutting down. A new CR is in effect until March 11, 2022.

A disadvantage of functioning under a CR is that departments and agencies must operate with last year’s funding levels. An inability to know how much money Congress eventually will provide for a wide assortment of programs means that long-term budget planning is upended. It also remains unclear whether new initiatives either can or should be set in motion. Another serious drawback affects government staffing levels because of the uncertainty of not knowing whether positions will continue to be funded. The Health Resources and Services Administration (HRSA) within the U.S. Public Health Services is an example of an agency influenced negatively by the prevailing uncertainty. Important programs involving community health centers for the delivery of needed services and health workforce training are two of many entities to benefit immensely by having clearer funding signposts in efforts to go forward effectively.

Giambattista Vico (1668-1744) was the author of La Scienza Nuova, a book that he wrote to decipher the history, mythology, and laws of the ancient world. His conception of history is that it unfolds in four stages: theocratic, aristocratic, democratic, and chaotic. In the last phase, everything falls apart, producing a ricorso that results in a return to the theocratic phase where the cycle begins all over again.

Perhaps a way of viewing the annual funding cycle on Capitol Hill might be to consider it as occurring in the following stages:

Dread—Funding finally was approved for this year. Is it really time to begin once again?
Conflict—Why cannot colleagues on the other side of the aisle simply agree with us this time?
Anxiety—Will an omnibus bill ever be passed before the current fiscal year ends?
Satiety—We did it.

Lastly, related to determining if passage of omnibus legislation is achievable, the issue of parity tends to arise every year. If money for social programs is going to be increased, shouldn’t funding for military purposes be increased equally? The same quagmire holds true vice versa.

DUELING IHD “SKIN” NARRATIVES

The genesis of the Framingham heart study in 1948 and the onset of the great era of cardiovascular core risk factor identification (e.g., high lipid levels) are credited with a precipitous decline in ischemic heart disease (IHD) mortality. Rather than lauding this triumph, some epidemiologists have mounted a substantial critique of “risk-factor” epidemiology in IHD, notwithstanding its documented public health value. This critique arises from quite different directions as described in the January 2022 issue of the journal Epidemiology.

Proponents of the social determinants of health argue that it is necessary to move far “above the skin” by examining larger social forces that give rise to the biologic markers conventional epidemiology has treated as causal factors in IHD. Conversely, supporters of the human genome project advocate probing yet further “beneath the skin” to demonstrate that the massive investment in genome-wide association studies and the coalescence of these findings into polygenic scores will open up new avenues for prevention. The two positions to some extent reflect the contrast between the reductionism attractive to molecular biologists and the holism to which social scientists are drawn.

The debate is enriched in the Epidemiology issue by inclusion of a study that brings together genetic and sociodemographic antecedents, providing a welcome attempt at integrating risk factors operating across different levels of organization. Sophisticated mathematical and statistical tools used in the study are indifferent to preconceived causal structures and they have the additional benefit of helping to constrain the prejudices of investigators. The commonality linking the two schools of thought represented is not often recognized. Both argue that it is a mistake to see conventional cardiovascular risk factors as causes. Both agree that they are mere biologic intermediaries determined by factors operating long before they are evident, whether those factors can be social forces or genetic differences.

Both schools also argue that it is necessary to go beyond conventional thinking about cardiovascular risk factors to understand fully the causes of IHD. As has often been noted, causality is not a straight line, but a messy matrix of interacting and intersecting factors operating at different times and at different levels. This consideration especially is true for IHD, which has no singular cause. Although this nexus frequently has been described as a web of causation, that metaphor does not do full justice to the complexity of influences operating on several levels.

Another paper appearing in the January 2022 issue of the journal Nature Genetics complements what is known about cardiovascular disease. Efforts to elucidate causal mechanisms, including large-scale sequencing studies, have resulted in thousands of genes being associated with cardiovascular and cardiometabolic diseases with varying degrees of evidence. The traditional reductionist paradigm, i.e., one disease–one target–one drug, or, if need be, a combination thereof, is insufficient to provide mechanistic explanations and enable actionable subtyping or endotyping of diseases for precision medicine.

PATIENT SATISFACTION AND EXPERIENCE WITH TELEMEDICINE

Telemedicine, a potentially disruptive innovation, has emerged as an indispensable pathway to provide continued health care services and improvise public health outcomes during the COVID-19 pandemic. Following the global appearance of the coronavirus, health care providers began postponing several routines, elective care, and outpatient services due to extensive deployment of medical resources in the treatment of patients and to decrease the risk of virus transmission. Another consequence is that face-to-face consultations were disrupted because of hesitation in consulting physicians in the hospital setting. As discussed in an article about patients’ satisfaction and experience with telemedicine that was published in the December 2021 issue of the journal Telemedicine and e-Health, partial or complete disruption of health care services for non-COVID diseases in many countries involved hypertension; diabetes and diabetes-related complications; cancer screening and treatment; cardiovascular emergencies; and rehabilitation. The most common reasons cited for disruption of health care services were lack of health workers’ availability, diversion of health workers to COVID-19 management, cancellation of planned treatments, and risk of virus transmission during on-site patient visits.

Telemedicine became a useful alternative towards streamlined response to the pandemic. Per the WHO, this modality is defined as the delivery of health care services by health care professionals using technology entailing the exchange of medical information for the diagnosis, treatment, and prevention of diseases and injuries. It includes synchronous mode (e.g., video visits, audio visits), asynchronous mode (e.g., emails), and remote monitoring of patients. Researchers sought to identify relevant studies published between December 2019 and August 2020 that highlighted patients’ satisfaction and experience with the use of telemedicine during the pandemic. The findings based upon 48,144 surveyed patients and 146 providers in 12 different countries revealed high satisfaction with virtual encounters across a spectrum of diseases. Telemedicine was found satisfactory on various outcome measures, such as addressing patients’ concerns, communication with health care providers, usefulness, and reliability. Most common advantages were time saved due to lesser traveling and waiting time, better accessibility, convenience, and cost efficiency. Age and sex did not have any significant impacts on satisfaction levels. Physicians and patients both showed a strong preference for continued usage and agreed upon telemedicine's potential to complement the regular health care services even after the pandemic.

THE CRISPR CHILDREN THREE YEARS LATER

The September 2021 issue of the newsletter TRENDS, featured an article on the topic of biological technology prospects, with an emphasis on CRISPR (clustered regularly interspaced short palindromic repeats). Designed as a tool for editing human genes, since it began to attract attention in the media in 2012, ethical discussions about the legal status of such editing have been generated. 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. Presently, the fate of these three-year-old toddlers remains shrouded in secrecy amid swirls of rumors. Many individuals who were contacted for an article published in the December 2021 issue of the journal Nature Biotechnology refused to speak about the children, who purportedly are healthy. Some respondents agreed to do so only on condition of anonymity.

The original goal of these heritable gene edits was to generate HIV-resistance by introducing germline mutations. The effort was roundly criticized by researchers and ethicists. Thus far, the children themselves have not received much attention. They are considered both celebrities and victims, with their health and well-being a closely held secret. Initially, it was envisioned that development and health would be monitored until their 18th birthdays. Upon reaching adulthood, the girls would be asked to re-consent in order for the testing to continue. An anonymous source indicates that the babies reportedly had medical checkups at birth, at one and six months of age, and at one year. Establishing how the edits to their genomes will translate into health benefits or risks later in life is challenging. Because of widely differing viewpoints on the potential impact of these edits on their physical and mental health, it is difficult to know what lies ahead for the girls.

OBTAINABLE RESOURCES

U.S. Healthcare Quality And Disparities
The Agency for Healthcare Research and Quality (AHRQ) has released its 2021 National Healthcare Quality and Disparities Report, which details the state of healthcare quality and disparities in the United States. Additionally, improvements in HIV and colon cancer care, nursing home care, and medication prescribing to older adults are identified. The report also indicates that more work needs to be performed to address disparities in important areas. Among the findings are the following:

• The numbers of individuals covered by health insurance and those who have a usual source of healthcare have increased significantly.

• Personal spending on health insurance and healthcare services decreased for those under age 65 with public insurance and increased for holders of private insurance coverage.

• Access to dental care and oral healthcare services remains low and has not substantially improved, particularly for individuals who have low income or who live in rural areas.

• A multiyear rise in opioid-related hospitalizations had been tapering off prior to the COVID-19 pandemic, but the opioid crisis has worsened markedly since then. Suicide death rates were rising in all groups for more than a decade before the pandemic. Since then, suicide deaths have decreased in White populations, but continue to rise in racial and ethnic minority populations. Limited access to substance abuse and mental health treatment may have contributed to these crises.

• Although Black, Hispanic, American Indian, and Alaska Native communities have experienced substantial improvements in healthcare quality, significant disparities in all domains of quality persist. Even when rates of improvement in quality exceeded those experienced by White Americans, the improvements have not been enough to eliminate disparities. The report can be obtained here.

State Trends In Employer Premiums And Deductibles, 2010–2020
Employer health insurance coverage has been relatively stable in recent years, falling only slightly during the COVID-19 pandemic. That news for the most part is encouraging, but costs for this coverage are on the rise. Unfortunately, the increase is constituting a larger share of workers’ paychecks. A new Commonwealth Fund report analyzing trends in employer plan premiums and deductibles across all states finds that over the last decade, incomes have not kept pace with health insurance costs, which are driven largely by high prices for drugs and health care services. In 37 states, premium contributions and deductibles together consumed as much as 10% or more of median household income in 2020, up from just 10 states a decade earlier. For single and family insurance policies, the average total cost of premiums and potential deductible spending ranged from a low of $6,528 in Hawaii to a high of more than $9,000 in five states, including Florida and Texas. The report can be obtained here.

Medicare Beneficiaries’ Use Of Telehealth In 2020
A new report from the U.S. Department of Health and Human Services (HHS) found that massive increases in the use of telehealth helped maintain some health care access during the COVID-19 pandemic, with specialists like behavioral health providers seeing the highest telehealth utilization relative to other providers. The report, which was produced by researchers in the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) analyzes Medicare fee for service (FFS) data in 2019 and 2020 and also highlights that telehealth services were accessed more in urban areas than rural communities. Black Medicare beneficiaries were less likely than White beneficiaries to use telehealth. The share of Medicare visits conducted through telehealth in 2020 increased 63-fold, from approximately 840,000 in 2019 to 52.7 million. States with the highest use of telehealth in 2020 included Massachusetts, Vermont, Rhode Island, New Hampshire and Connecticut. States with the lowest use of telehealth in 2020 included Tennessee, Nebraska, Kansas, North Dakota, and Wyoming. The report can be obtained here.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

COVID Impact On Employment Status Of LGBTQ+ Individuals
COVID-19 has had a disproportionate impact on employment for minority population sub-groups resulting in higher unemployment rates and health care concerns, according to a study from Rutgers University that was published on November 13, 2021 in the journal Sexuality Research and Social Policy. The aim of the investigation was to identify the specific effects of job loss trends on LGBTQ+ individuals in the U.S. The results indicate that employment of members of this group has been undermined by COVID-19, but as with all population segments, those individuals with multiple minority identities, such as Black or HIV+ and LGBTQ+, have been affected most severely. This study highlights the need for national data collection on sexual orientation and gender identity for unemployment as well as the need for substantive policies, such as expanding unemployment to assist in the economic recovery for population groups most affected by COVID-19, along with the Equality Act to offer further workplace protections.

Trends In Adolescent Cannabis-Related Hospitalizations By State Legalization Laws, 2008-2019
The impact of cannabis legalization on adolescent cannabis-related hospitalizations remains unknown. An investigation described in the December 2021 issue of the Journal of Adolescent Health sought to assess whether state cannabis legalization is associated with adolescent cannabis-related hospitalizations. The study involved states with no legal use to medical cannabis laws (MCLs) and states with MCLs to nonmedical (>21 years old) cannabis laws (NMCLs). Of 1,898,432 adolescent hospitalizations in 18 states and Washington, DC, there were 37,562 (2%) hospitalizations with a cannabis-related diagnosis, with 8,457 (23%) in states with no legal use, 20,444 (54%) in MCL states, and 8,661 (23%) in NMCL states. Among the conclusions reached, cannabis-related adolescent hospitalizations at children’s hospitals are increasing, with a disproportionate increase post-legalization in states with NMCLs. Interventions are warranted to increase cannabis use identification and treatment among at-risk adolescents in the hospital-based setting.

HEALTH TECHNOLOGY CORNER

Factors Involving 10-Year Declines in Physical Health and Function Among Women During Midlife
Women in midlife often develop chronic conditions and experience declines in physical health and function. Identifying factors associated with declines in physical health and function among these women may allow for targeted interventions. As reported in a cohort study described on January 10, 2011 in the journal JAMA Network Open, the objective by investigators at Brigham and Women’s Hospital was to examine factors associated with clinically important 10-year declines in the physical component summary score (PCS) of the Short Form 36 (SF-36), a widely used patient-reported outcome measure, in women in midlife. The findings reveal that clinically important declines in women’s physical health and function were relatively common between ages 55 and 65 years. Several variables associated with these declines were identified as potentially useful components in a clinical score identifying women at increased risk of physical health and functional declines.

How Skin Cells Form A First Line Of Defense Against Cancer
A study published on January 11, 2011 in the journal Cell Reports reveals important insights into the molecular mechanisms that underpin the body’s natural defenses against the development of skin cancer. The findings offer new clues into the behavior of skin cancer at the cellular level, paving the way for potential new therapeutic targets to treat the disease. The investigation by researchers at the Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology in Spain, indicates that the protein CSDE1 coordinates a complex chain of events that enable senescence in skin cells. The senescent cells act as a firewall against cancer, suppressing the formation of tumors. The findings are surprising because CSDE1 previously has been linked to driving the formation of cancers. The study is one of the few to examine the role of RNA-binding proteins in establishing cell senescence, which is an important new frontier in cancer research.

DEVELOPMENTS IN HIGHER EDUCATION

The year 2022 began with the number of Covid-19 case counts mounting steadily due to the more transmissible Omicron variant. Some leaders of higher education institutions have responded by either choosing to begin the spring semester online or delay the date when faculty, staff, and students will be allowed to return to campus. Administrators in school districts around the nation have had to make similar decisions for elementary and secondary institutions. Apart from risks associated with experiencing physical symptoms of the disease, adverse mental health effects related to the coronavirus also are considered to be quite worrisome.

The Biden Administration has played an active role in trying to keep schools safely open for full-time, in-person instruction. These efforts have resulted in 96% of schools opening on an in-person basis in January 2022, up from 46% of schools in January 2021. New initiatives will lead to an increase in the number of COVID-19 tests available to schools by 10 million per month. During the past year, federal funding provided to states and school districts across the nation, including $130 billion in the Elementary and Secondary School Emergency Relief is directed toward safely reopening schools and addressing students’ academic and mental health needs. Another $10 billion in the Epidemiology and Laboratory Capacity (ELC) cooperative agreement is being used to support COVID-19 testing for students and staff.

Unified Agenda And Regulatory Plan
The Fall 2021 Unified Agenda and Regulatory Plan was published on December 10, 2021. The U.S. Department of Education anticipates issuing the Title IX notice of proposed rulemaking by April 2022, a month earlier than the May 2022 date listed in the Spring 2021 Unified Agenda. The Department is deeply committed to: ensuring that schools are providing students with educational environments free from discrimination in the form of sexual harassment; ensuring that schools have grievance procedures that provide for the fair, prompt, and equitable resolution of reports of sexual harassment and other sex discrimination; and addressing discrimination based on sex, including sexual orientation and gender identity, in educational environments. In line with those commitments, the Department also has expressed its intent to propose amendments to its regulations implementing Title IX to address these issues.

Student Loan Pause Extended
The Department on December 22, 2021 announced a 90-day extension of the pause on student loan repayment, interest, and collections through May 1, 2022. The extension will allow the Administration to assess the impacts of the Omicron variant on student borrowers and provide additional time for borrowers to plan for the resumption of payments and reduce the risk of delinquency and defaults after restart. The pause will help 41 million borrowers save $5 billion per month. This action is part of a series of steps the Biden Administration has taken to support students and borrowers, make higher education more affordable, and improve student loan servicing, including providing nearly $13 billion in targeted loan relief to over 640,000 borrowers. Specific examples include providing $7.0 billion in relief for 401,000 borrowers who have a total and permanent disability, and helping 30,000 small business owners with student loans seeking help from the Paycheck Protection Program.

Negotiated Rule-Making Committee Expected To Address Unresolved Issues
As the year 2022 unfolds, it is likely that efforts will be undertaken by the Department’s Negotiated Rule-Making Committee to reach agreement on some contentious issues. Prominent examples are:

• How the Education Department processes and adjudicates claims for loan forgiveness by borrowers who are defrauded by their college as well as the circumstances in which borrowers are entitled to loan forgiveness when their college suddenly closes.

• How to structure the administration’s new income-driven repayment plan and how to expand the Public Service Loan Forgiveness program.

HEALTH REFORM DEVELOPMENTS

Another section of this December 2021-January 2022 issue of the ASAHP newsletter TRENDS has a list of three obtainable resources electronically that pertain to: health care disparities; uneven allocation of health insurance deductibles and premiums among consumers in different states in the U.S.; and how usage of telehealth services by Medicare beneficiaries varies around the nation based on ethnicity and urban-rural residence patterns. Policymakers at the national level often discuss where the locus of control might best be centered in dealing with such matters. The federal government has enormous resources at its disposal to respond to a wide range of health problems. As an illustration, although 21 major federal agencies in more than 100 offices are spread around the U.S. to combat the COVID pandemic, it remains highly challenging to develop an effective administrative structure to coordinate all these entities to prepare for and respond to this disease. Another potential downside is that any effort resembling a one-size national approach may lack the necessary heft to meet the kinds of various situations that exist around the nation.

Perhaps even more importantly, centralization of authority rests on a major assumption that effective action can be taken in the face of an enormous amount of administrative diversity that exists within states, counties, cities, and towns. Whenever a health problem arises, health departments at each of these levels have different capabilities in the form of possessing suitable amounts of key staff and the resources necessary to produce desirable outcomes. These governmental units also differ significantly from one another based on the kinds of consumers being served. Demographic factors, such as age, race/ethnicity, degree of health insurance coverage, and urban-rural residential patterns all play a determinative role in how successfully local health problems can be addressed. One-size remedies promoted nationally often tend to lack more customized interventions needed to deal with the wide variability that characterizes local jurisdictions.

Expansion Of Health Insurance Coverage
On the plus side of noteworthy developments, the Biden Administration’s American Rescue Plan has made it possible for millions of more consumers' to become eligible for health care coverage that began January 1, 2022 through the Affordable Care Act (ACA) Health Insurance Marketplaces. The effort started on November 1, 2021 and had a closing date of January 15 this year while managing to outpace previous years’ enrollment. Total nationwide plan selections include more than 14 million consumers (15% of the total) who are new to the Marketplaces for 2022 and returning consumers (85% of the total) who have active 2021 coverage and made a plan selection for 2022 coverage or were re-enrolled automatically.

Rural Health Care Developments
The Agency for Healthcare Research and Quality (AHRQ) released an updated Chartbook on Rural Healthcare that discusses how rural area inhabitants face difficulty obtaining timely, high-quality, affordable services. Approximately 60 million Americans live in rural communities that often are a considerable distance from needed resources, which can add to the burden of obtaining care. Census Bureau data show that about 20% of the population lives in rural or nonmetropolitan areas, although about 85% of the total U.S. land area is classified as rural. Ten million rural residents identify as Black, Hispanic, American Indian/Alaska Native, Asian American/Pacific Islander, or mixed race. One in five rural residents belongs to one or more of these groups. Regrettably, availability and collection of robust data on health outcomes of these population groups remain limited. Also, compared with urban counties, their rural counterparts differ in fundamental ways, such as having a higher prevalence of adults with multiple chronic health conditions (e.g., arthritis, diabetes) (34.8% vs. 26.1%).

COVID-19 Effect On Health Care Expenditures
The COVID-19 pandemic has had a dramatic impact on the nation’s health sector in 2020, driving a 9.7% growth in total national health care spending as it rose to $4.1 trillion. This figure is one of many health care expenditures presented in the 2020 National Health Expenditures (NHE) Report, prepared by the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS). Medicare spending totaled $829.5 billion in 2020, representing 20% of total health care spending. Medicaid spending grew faster in 2020, increasing 9.2% to $671.2 billion compared to 3.0% growth in 2019, primarily driven by increased enrollment due to the pandemic.

SEASONAL UNCERTAINTIES

The 2nd Session of the 117th Congress was launched in January 2022, but a picture of what will unfold in coming months continues to be somewhat opaque. For example, the likelihood of passing a multi-trillion dollar “Build Back Better” tax and spending reconciliation package (H.R. 5376) previously has been discussed in this newsletter. An important piece of legislation, its aims involve expanding Medicare to include hearing, two free years of community college, universal pre-kindergarten, and creation of a program encouraging utilities to reduce carbon emissions. Opponents contend that not only are some components of the bill wasteful, but also have the potential through proposed tax increases to inflict substantial harm on the overall economy. As with other large proposed spending measures, debates focus on how to finance the various provisions, especially if increased taxation is required.

The ongoing presence of the coronavirus pandemic keeps alive concerns that perhaps additional federal efforts are needed to ensure that enough is being accomplished in the related areas of vaccine distribution and development of effective therapeutics. Specifically, Congress may need to decide that more funding is necessary to address these aspects of health protection for the U.S. population. One possibility might be to produce an emergency supplemental spending package aimed at furnishing more resources to increase hospital and testing capacity.

More generally, February 18 has been designated as a deadline to continue federal government funding for the rest of the current fiscal year that draws to a close on September 30. As in previous years, it is proving difficult to agree on what the total amount of spending should be. Legislators do not appear to be close to reaching an agreement on either total spending or whether to rely on either another stopgap spending bill or an omnibus package.

Unlike 2021, the 2nd Session of the 117th Congress will not last as long as the 1st Session because of the upcoming midterm elections. Viewed from the perspective of bills that involve the topic of health, in 2021 there were 795 bills introduced in the House and 464 in the Senate. Often, many bills are companion pieces and have the same contents offered for consideration by legislators in each chamber. Despite these relatively large numbers, each year a much smaller group ever makes it to the enactment stage. In 2021, the following measures attained that status: P.L. 117-71, Protecting Medicare and American Farmers from Sequester Cuts Act; P.L. 117-11, FASTER Act of 2021; P.L. 117-9, A Bill to Amend the Federal Food, Drug, and Cosmetic Act with Respect to the Scope of New Chemical Exclusivity; and P.L. 117-8, Advancing Education on Biosimilars Act of 2021.

As the year progresses, it is likely that more individuals will announce that they will not seek reelection in the midterm races that will be decided next November. Some legislators plan to run for a different kind of office, but most are retiring for other reasons. If Republicans eventually assume control in both chambers, the change could have a negative impact on the ability of President Biden to achieve his policy agenda.

TECHNOLOGICAL IMPACTS ON HEALTH

The arrival of the coronavirus in the U.S. nearly two years ago immediately began producing enormous changes in the workplace. As a result of lockdowns and social distancing policies around the nation, chief among these alterations was that millions of workers lost their jobs. Fortunately for certain kinds of employees, many of them were able to remain at home performing essential tasks. In the health professions, tools such as Zoom and telehealth made it possible for many educators, students, and clinicians to function successfully without having to be in an office, classroom, or clinic.

Less well heralded, but still of increasing relevance apart from the pandemic, are many technological developments with the potential to transform not only the workplace, but also to have an impact on enhancing individual and community health status. For example, newer direct-reading sensor devices are incorporating recent advances in electrochemical, optical or mechanical transducers; nanomaterials; electronics miniaturization; portability; batteries with high-power density; wireless communication; energy-efficient microprocessing; and display technology. Commercial applications of new sensor technologies have led to a variety of health and lifestyle management devices for everyday life. These digital health technology tools, such as fitness trackers, smartwatches, and smartphones function as real-time monitors of various physiological and disease-related signals. Technologies of this nature have led to advances in connected health, telemedicine, sports analytics, ambient intelligence, and workplace “physiolytics.”

According to an article published in the January 2022 issue of the American Journal of Industrial Medicine, existing and newer sensor technologies can be categorized into broad categories. Placeable sensor devices can be placed in and around the workplace to collect information from the ambient work environment. The vast majority of extant Wearable sensors can be attached to a worker's clothing, head, arms or wrists, upper/lower body, or feet, worn as computer-display eyeglasses, or contact lenses, or placed in the ear canal. Moreover, current research into the role of wearable sensing technologies in the construction industry has focused on how sensors can aid in detecting and monitoring risk factors that lead to work-related musculoskeletal disorders (WMSDs), falls from elevated heights, and physical fatigue. Implantable sensors constitute a third variety of new items that can be inserted into the skin via microneedles, microchips, or by ingestion.

As these new implements become more commonplace, key questions arise. One is which population subgroups will tend to benefit most from the widespread adoption of such technological instruments? Closely related to the issue of which individuals will be able to obtain products that can enhance their personal health status is the important matter of how to pay for them. Substantial portions of the U.S. population are at a major disadvantage that results from health care inequities. The major health care financing programs Medicare and Medicaid are not in an enviable position to absorb new significant expenditures to ensure that health technology innovations are spread equitably across the population.

RESIDENTIAL DISORDER AND BIOLOGICAL MARKERS OF AGING

Residential context is important to older adults’ health. Numerous studies have linked adverse residential conditions, such as physical disorder, to poorer functional status, chronic health conditions, and cognitive decline. A growing literature investigating possible physiologic pathways between residential contexts and health has focused on biological markers. As indicators of normal biological processes, biomarkers may reflect aging-related health and functional changes and have been linked to morbidity and mortality. For example, inflammatory markers, such as C-reactive protein (CRP) and interleukin-6 (IL-6), are associated with physical function decline, cardiovascular disease, and mortality in older adults, but the underlying biologic mechanisms remain understudied. Thus, examining the relationships between adverse street block conditions and biomarkers of aging would further an understanding of the physiological mechanisms through which residential context influences aging and health. A study described in the November 2021 issue of the Journals of Gerontology Series A: Biological Sciences and Medical Sciences was to test associations between adverse street block conditions and biomarkers of aging among a nationally representative cohort of US adults aged 67 years and older.

The investigators posit that smaller area units should be considered because older adults’ life space can decrease with the onset of age-related health or functional limitations. Conditions of the residential environment proximate to the home, such as the street block on which the home is situated, may be more influential in older adults’ everyday lives than the wider neighborhood context. They hypothesized that the presence of any street block disorder is associated with higher levels of four biomarkers of aging: hemoglobin A1C, high-sensitivity CRP, IL-6, and CMV antibodies. They found that participants living on disordered blocks were more likely to be Black or Hispanic than White, have a high school education or less, and have a lower average income to poverty ratio compared to participants living on blocks with no disorder. These participants also were more likely to experience financial strain, be unmarried, rent their home, have a larger mean household size, live in a non-single-family type home, have had less than average family wealth growing up, and have been born outside the United States.

TRENDS IN HEALTH STATUS ACROSS A CENTURY OF U.S. BIRTH COHORTS

Following decades of improvement in functioning and a decline in disability among the U.S. population aged 65 or older, newer cohorts approaching middle-age (ages 40–59) and “young old” (ages 60–69) began to experience increasing functional limitations and disability starting in the late 1990s. The worsening disability trend is accompanied by increasing mortality rates in middle age around the early 2000s, which were thought to be driven by rising “deaths of despair” (drug-, alcohol-, and suicide-related mortality) combined with slowdowns in progress in heart disease mortality. Suicide, cirrhosis of the liver, and fatal drug overdoses suggest that victims are likely suffering from psychological distress. The rising mortality rate narrative initially was only applied to the White population. Subsequent research, however, suggests it is not restricted to that population subgroup.

According to an article appearing in the November 2021 issue of the American Journal of Epidemiology, important research gaps remain. An example is that studies only look at the end of the morbidity process, which begins for populations with the physiological dysregulation (PD) indicated by a number of biological risk factors and followed by subsequent diagnosis of diseases, functioning loss, disability, frailty, and death. Mental illness (e.g., anxiety and depression) and health behaviors also precede the onset of disability and mortality. Thus, it is essential to investigate whether the unfavorable trend in morbidity and mortality in recent decades should be attributed to health behavior changes driven by psychological distress, deterioration of innate physiological functioning, or both. As a means of addressing various gaps, a comprehensive investigation is described of the trends of physiological status, mental health, and health behaviors by race and sex across a century of birth cohorts that were classified on the basis of nine generations. These researchers found that the worsening physiological and mental health profiles among younger generations imply a challenging morbidity and mortality prospect for the United States, one that might be particularly inauspicious for Whites.

OBTAINABLE RESOURCES

Annual Report To The Nation On The Status Of Cancer

Part 1 of the latest Annual Report to the Nation on the Status of Cancer was focused on national cancer statistics and it became available on July 8, 2021. Part 2, appearing October 26, 2021, in JNCI: The Journal of the National Cancer Institute, is the most comprehensive examination of patient economic burden for cancer care to date and includes information on patient out-of-pocket spending by cancer site, stage of disease at diagnosis, and phase of care. While this analysis is about the costs that are directly incurred by patients, which are critical to patient finances, the total overall costs of cancer care and lost productivity in the United States are much larger. Among adults aged 65 years and older who had Medicare coverage, average annualized net out-of-pocket costs for medical services and prescription drugs, across all cancer sites, were highest in the initial phase of care, defined as the first 12 months following diagnosis ($2,200 and $243, respectively), and the end-of-life phase, defined as the 12 months before death among survivors who died ($3,823 and $448, respectively), and lowest in the continuing phase, the months between the initial and end-of-life phases ($466 and $127, respectively). Across all cancer sites, average annualized net patient out-of-pocket costs for medical services in the initial and end-of-life phases of care were lowest for patients originally diagnosed with localized disease compared with more advanced stage disease. Part 1 can be obtained here. Part 2 can be obtained here.

Prison And Jail Reentry And Health

Another section of this month’s edition of the ASAHP newsletter TRENDS discusses incarceration in the context of astrobiology. Mass imprisonment in the United States can be viewed as a public health crisis that has disproportionate negative impacts on communities of color. The reentry population, i.e., individuals released back to the community following incarceration, is sicker than the general population, faces barriers to accessing health care, and often experiences homelessness, unemployment, and a lack of social and family support. A new Health Affairs Policy Brief dives deeper into the link between community reentry and health. The authors provide an overview of research regarding the health outcomes and challenges associated with prior incarceration, a review of strategies currently used to support the health and well-being of the reentry population, and recommendations to improve health and justice outcomes. They indicate that criminal justice reform coupled with targeted upstream efforts, such as investment in criminal justice-based reentry programs; support for communities and the community health systems to which inmates return; and enhanced research evaluation of reentry programming are necessary to mitigate the negative health impacts of mass incarceration. The policy brief can be obtained here.

2020 National Survey Of Drug Use And Health

A first findings report summarizes key findings from the 2020 National Survey on Drug Use and Health (NSDUH) for national indicators of substance use and mental health among individuals aged 12 years old or older in the civilian, noninstitutionalized population of the United States. The findings indicate that among the group aged 12 or older in 2020, 58.7% (or 162.5 million individuals) used tobacco, alcohol, or an illicit drug in the past month (also defined as “current use”), including 50.0% (or 138.5 million) who drank alcohol, 18.7% (or 51.7 million) who used a tobacco product, and 13.5% (or 37.3 million) who used an illicit drug. Among members of the group aged 12 or older, 20.7% (or 57.3 million) used tobacco products or used an e-cigarette or other vaping device to obtain nicotine in the past month. Among adults aged 18 or older, 21.0% (or 52.9 million) had any mental illness (AMI) and 5.6% (or 14.2 million) had serious mental illness (SMI) in the past year. The report can be obtained here.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Suicide Rates By Month And Demographic Characteristics: United States 2020

The November 2021 issue of a report from the National Vital Statistics System refers to provisional numbers of deaths due to suicide by demographic characteristics (sex and race and Hispanic origin), and by month for 2020, and compares them with final numbers for 2019. The overall age-adjusted suicide rate declined 3%, with the decline for females (8%) greater than males (2%). Rates for persons aged 10–34 were higher in 2020 than in 2019, whereas rates for persons aged 35 and over were lower. The increases for those aged 25–34 and the declines for those aged 35–74 were significant. The changes in suicide rates by age between 2019 and 2020 were generally similar for both males and females, although only males had a significant increase at ages 25–34. All race and ethnicity groups for women had declines in age-adjusted suicide rates from 2019 to 2020, although only the 10% decline for non-Hispanic white women was significant statistically.

Access To Care And Mental Health Services By Household Income During COVID, U.S.

Since the start of the COVID-19 pandemic in March 2020, approximately 40% of U.S. adults have experienced delayed medical care. As described on November 9, 2021 online in the journal Health Equity, researchers used the Census Bureau's nationally representative pooled 2020 Household Pulse Survey from April to December, 2020 (N=778,819) to analyze trends and inequalities in various access to care measures. During the pandemic, the odds of being uninsured, having a delayed medical care due to pandemic, delayed care of something other than COVID-19, or delayed mental health care were, respectively, 5.54, 1.50, 1.85, and 2.18 times higher for adults with income <$25,000, compared to those with incomes ≥$200,000, controlling for age, sex, race/ethnicity, education, marital status, housing tenure, region of residence, and survey month. Income inequities in mental health care widened over the course of the pandemic, while the probability of delayed mental health care increased for all income groups.

HEALTH TECHNOLOGY CORNER

Mathematical Model For Checkpoint Inhibitor Therapy In Human Solid Tumors

Checkpoint inhibitor therapy of cancer has led to markedly improved survival of a subset of patients in multiple solid malignant tumor types, yet the factors driving these clinical responses or lack thereof are not known. As reported on November 9, 2021 in the journal eLife, researchers from The Houston Methodist Research Institute and several other institutions developed a mechanistic mathematical model for better understanding these factors and their relations in order to predict treatment outcome and optimize personal treatment strategies. The results have demonstrated reliable methods to inform model parameters directly from biopsy samples, which are conveniently obtainable as early as the start of treatment. Together, these suggest that the model parameters may serve as early and robust biomarkers of the efficacy of checkpoint inhibitor therapy on an individualized per-patient basis. The model could provide a way of identifying patients who will benefit from immunotherapy at an early stage in their cancer treatment.

Effect Of A Diagnosis Of Alzheimer's Disease And Related Dementias On Social Relationships

Although early diagnosis has been recognized as a key strategy to improve outcomes of Alzheimer's disease and related dementias (ADRD), the effect of receiving a diagnosis on patients' well-being is not well understood. A study conducted by investigators at Rutger University that was described on October 14, 2021 online in the journal Dementia and Geriatric Cognitive Disorders addresses this gap by examining whether receiving a dementia diagnosis influences social relationships. Data from the three waves (2012, 2014, and 2016) of the Health and Retirement Study were used as part of this study. Results suggest that receiving a new diagnosis of ADRD may have unintended impacts on social relationships. Practitioners and policymakers should be aware of these consequences and should identify strategies to alleviate the negative impact of receiving a diagnosis of ADRD and methods to mobilize support networks after receiving a diagnosis.

DEVELOPMENTS IN HIGHER EDUCATION

It is not uncommon today to learn of distressful events that are experienced by students enrolled in higher education programs. One example of a negative impact on some individuals is that they complete their formal learning period with a mountain of student loan debt, which is most difficult to repay because of low employment salaries upon leaving the academy. As a consequence, it may be more difficult for them to achieve what their parents were able to accomplish much more easily, such as being able to purchase a home or retire at a relatively early age.

Nonetheless, some benefits of a higher education continue to persist. An infogram developed on November 10, 2012 by the American Council on Education (ACE) reveals that increased annual earnings are available at each level when moving from the category high school diploma or equivalent ($31,956) to the category graduate or professional degree ($75,495). Whereas only 6% of adults holders of a bachelor's degree or higher are less likely to smoke, among the group with a high school diploma or equivalent, that figure is 23%. Adults with a bachelor’s degree or higher (65%) are more likely to meet exercise guidelines than possessors of a high school diploma or equivalent (43%). Moreover, adult degree holders and those with some college, but no degree, represent a larger share of workers (69%) than those with a high school diploma or less (32%).

Impact Burden Of And Solutions For FAFSA Verification

The Free Application for Federal Student Aid (FAFSA) unlocks access to federal financial aid programs, including the cornerstone of need-based aid: the Pell Grant. Millions of postsecondary students complete the FAFSA annually, but a significant portion of them cannot receive their aid without completing an additional, lengthy process called verification to confirm that their FAFSA is accurate. Without completion of this audit-like process, students are unable to access federal financial aid, and in many cases state or institutional financial aid. Verification recently has come under scrutiny for its questionable value to the taxpayer and the burden it places on students and institutions. Concerns include the question, is the burden worth the impact on financial aid offices when one in five financial aid administrators spend at least half their time on the verification process?

The National College Attainment Network (NCAN) and the National Association of Student Financial Aid Administrators (NASFAA) joined together to survey both financial aid administrators as well as college access and success advisers on the impact of verification on their students and their work within this landscape of verification relief and scrutiny. In a paper released by the two organizations in November 2021, an exploration looks at those experiences and offers recommendations to decrease the burden verification places on students and financial aid administrators alike.

CBO Cost Estimates For The Build Back Better Act

The Congressional Budget Office (CBO) was requested by Capitol Hill legislators to prepare a cost estimate for the current version of H.R. 5376, the Build Back Better Act (Rules Committee Print 117-18). Provision of this information likely will affect the vote eventually taken on this bill. Several provisions of this proposed legislation pertain to higher education. Title II, Subtitle A, Part 2 discusses these components of H.R. 5376. One example is increasing the maximum federal Pell Grant for enrollment of students at institutions of higher education. A related aspect involves an increase in these grants for recipients of means-tested benefits.

Another provision focuses on retention and completion grants to enable various eligible entities to carry out specific activities, such as expanding evidence-based reforms or practices to improve student outcomes at institutions of higher education in the State or system of institutions of higher education, and how an eligible entity will sustain such reforms or practices after the grant period ends. Priority will be given to entities that propose to use a significant share of grant funds for groups, such as students of color and low-income students.

HEALTH REFORM DEVELOPMENTS

Health care in this nation is affected by a wide range of social forces, including demographic perturbations. An opinion item published on November 10, 2021 in The Milbank Quarterly discusses some implications of a recent sharp decline in birth rates in the United States. Based on provisional data provided by the National Vital Statistics System in May 2021, the U.S. birth rate dropped 4% in 2020 and already was at a record low before the COVID-19 pandemic. The 2020 birth rate was 55.8 live births for every 1,000 females ages 15-44, trending downward for the sixth consecutive year.

The total fertility rate (TFR), a population statistic that simulates the average number of children females in a birth cohort will have if they go through life with current age-specific birth rates, also is trending downward. The TFR in the United States plummeted from 2.12 in 2007 to a record low of 1.64 in 2020, which is far below the level of 2.1 needed for population stability. When the TFR drops below 2.1 (the break-even replacement level), a population will age dramatically in the absence of immigration. Will such an occurrence pose societal challenges?

A major concern is that the reduced rate contributes to labor shortages and also will increase the population “total dependency ratio,” i.e., the ratio of the number of individuals in age groups not typically in the labor market (0-14 and 65+ years) to the number in all other age groups, multiplied by 100. U.S. Census Bureau data show that the U.S. dependency ratio was 59 in 2010, 64 in 2019, and is projected to be 73 by 2050 primarily due to population aging from the 1946-1964 Baby Boom. Additional declines in birth rates without offsets from immigration will further increase the dependency ratio, which raises serious concerns about economic stability/growth and the ability of the working population to support the social, financial, and health care needs of the dependent population. Policy-makers are faced with the task of devising workable interventions to prevent any deterioration in the nation’s ability to address the population’s health care needs effectively.

Why Measurement Matters In Advancing Health Equity

A blog published on November 2, 2021 by The Commonwealth Fund refers to how the COVID-19 pandemic exposed long-standing racial and economic injustices embedded in the U.S. health care system. One result is a renewed commitment to improve health equity and address the drivers of health (DoH) that account for 80% of health outcomes and have a disproportionate impact on communities of color, including stable, affordable housing; healthy food; reliable income; and interpersonal safety, among other factors. Advancing health equity and addressing DoH will require changing both how and what is measured in health care. Measurement plays a fundamental role because it equips providers with data to identify and address unmet needs, and allows policymakers and payers to account for DoH in payment models.

Despite the well-documented impact of DoH on health outcomes and costs and their impact on people of color, there still are no approved, standardized measures in any Centers for Medicare and Medicaid Services’ (CMS) programs. Although a growing number of CMS Innovation Center models are incorporating DoH screening and navigation on social needs, they use different tools and approaches, which means that CMS cannot systematically compare or use the data. On the positive side, the recently released CMS Innovation Center Strategy Report will require participants in all new models to collect and report beneficiaries’ demographic data and social needs data, when appropriate.

HealthCare.gov Open Enrollment Begins

November 1, 2021 marked the start of the HealthCare.gov Open Enrollment Period. This year, the period has been extended to January 15 to ensure that enough time is available to obtain health insurance coverage. The number of Navigators to assist with the process of obtaining coverage has been quadrupled so that now there are 1,500 of them. As a result of the American Rescue Plan (ARP), coverage also is more affordable. Four out of five individuals can find a plan for $10 or less per month with this newly expanded financial assistance. Additionally, there are more coverage options this season than last, with the average consumer being able to choose between six and seven insurance companies with plan options.

ALLIED HEALTH WORKFORCE DIVERSITY

Health policy discussions often involve topics, such as the need to provide coverage for individuals who either lack adequate health insurance or who have none at all, along with a steady escalation in health care costs. Generally, the health workforce does not attract as much attention. An implicit assumption seems to be that not only are their sufficient numbers of clinicians, educators, researchers, and students wanting to enter the health care realm, but also that there is no difficulty retaining them afterwards. Unfortunately, that ideal state fails to exist. An aging population with a growing number of patients with multiple co-morbidities acting in concert with portions of the health workforce that is moving just as rapidly into old age brackets and also is at risk of diminishing in size because of deaths and retirements. These conditions provide a rationale for the necessity of having policymakers be on the alert to conditions that influence this component of the health care spectrum.

A positive sign in that direction is some legislation pending on Capitol Hill. H.R. 3320, the Allied Health Workforce Diversity Act of 2021, was introduced in the House of Representatives on May 18, 2021. This measure allows the Department of Health and Human Services (HHS) to provide grants to accredited education programs to increase diversity in the physical therapy, occupational therapy, respiratory therapy, audiology, and speech-language pathology professions. Grants may be used to provide scholarships or to support recruitment and retention of students from underrepresented groups. Two days later, this legislation was referred to the Subcommittee on Health of the Committee on Energy and Commerce. Next, on November 4, following subcommittee consideration at a mark-up session, the bill was forwarded to the full committee by voice vote where on November 17, the full committee voted to advance the bill. A related bill, S. 1679, was introduced in the Senate on May 18 and referred to the Health, Education, Labor, and Pensions Committee where it currently sits awaiting further action.

In the event the proposed legislation reaches approval in both the House and the Senate, and is signed into law by President Biden, scholarships or stipends would be provided for: completion of an accelerated degree program; completion of an associate’s, bachelor’s, master’s, or doctoral degree program; and entry by a diploma or associate’s degree practitioner into a bridge or degree completion program. Another provision would furnish assistance for completion of prerequisite courses or other preparation necessary for acceptance for enrollment in the eligible entity; and carry out activities to increase the retention of students in one or more programs in the professions of physical therapy, occupational therapy, respiratory therapy, audiology, and speech-language pathology.

Meanwhile, President Biden signed into law on November 15 the one trillion dollar Infrastructure Investment and Jobs Act (H.R. 3684). The bill was approved by the House on a vote of 228-206, which included 13 Republicans. The Senate approved this legislation in August, with 19 Republicans voting to approve it. The next major legislation on the agenda involves roughly $2 trillion for health care, education and climate-change in what is called the “Build Back Better” reconciliation package. Legislators are waiting for an official Congressional Budget Office (CBO) cost estimate of the bill (H.R. 5376). The CBO is releasing estimates for individual titles of bills as they are completed.

ASTROBIOLOGY AND INCARCERATION

A pair of words characteristically not often found in the same sentence is the science of astrobiology and incarceration. The following comments about both realms is predicated on the assumption that the health status of individuals confined to the nation’s jails and prisons is mostly hidden from general view. Although social debates rage over issues regarding whether punishments that result in incarceration are either too excessive or not harsh enough, a proposition is advanced that insufficient attention tends to be paid to the physical and mental health of the imprisoned subset of the population.

Increases in the older inmate cohort in prisons are attributable in part to a growth in the number of first-time aging offenders, elimination of parole, increased sentence lengths that include life terms, and mandatory minimum sentencing. Moreover, older prisoners require different levels of care due to increased physical and mental comorbidity burden. Compared with their younger counterparts, older incarcerated patients reflect high rates of diabetes mellitus, cardiovascular conditions, and liver disease. Cardiovascular disease is significant because it is a leading cause of death among prisoners. Mental health problems also are common, especially anxiety, fear of death or suicide, and depression. A related concern is that correctional health care, whether provided by the government or the private sector, may not be subject to the same quality standards as the general health care system. Another important consideration is that many prisoners enter the correctional system with pre-existing physical and mental health problems.

According to a paper in the November 2021 issue of the journal Astrobiology, introducing educational programs into prisons has been shown to be beneficial not only for the richness of opportunities offered to prisoners, but also in efforts to reduce crime. An approach to prison education is to ask the question: what features of the prison environment give its inhabitants experience and knowledge that are unique to them and not experienced by members of the non-incarcerated population? If such aspects can be identified, then an opportunity may exist to allow prisoners to use that experience to contribute new ideas to society. Of some interest is that prisons bear similarities to planetary sites in remote locations that include relative isolation and confinement of the enclosed population compared to the external population, where limited interactions occur with participants in the larger outside world. Hence, the incarcerated possibly could be in somewhat of an advantageous position to have a deep intuitive understanding of the challenges of existing in a small relatively isolated population.

An endeavor in Scotland called the Life Beyond project involves the prison population in designing settlements for the planetary bodies Moon and Mars. Apart from improving educational opportunities in prisons, this initiative demonstrates the potential for prisoners to contribute to space settlement by applying their experience of the prison space analog environment. A conspicuous development is how the project rapidly expanded beyond the objective of science and engineering into creative writing, art, music, political philosophy, and other disciplines.

NEW INSIGHTS ON THE DETERMINANTS OF HEALTH TECHNOLOGIES USAGE

The future of health care in society is strongly tied to technology as sensors, wearable devices, and telemedicine continue to shift the health care paradigm. One such technology is the electronic (e-health) health portal, which provides patients with electronic access to their own medical information, allowing them to view their medical records and to interact with their clinicians. Several documented benefits of portal use to both patients and health care personnel have been identified, but adoption continues to lag in comparison with other technologies. The lack of adoption of e-health technologies in any segment of the population (e.g., elderly patients and immigrants) can create wide health care disparities that should be addressed. A study described in the September 2021 Special Issue of the journal Cyberpsychology, Behavior, and Social Networking was aimed at understanding the critical success factors and barriers for e-health portal use.

The researchers investigated the role of information privacy and security, and identified factors that influence the known antecedents of adoption intentions. An analysis of 836 data records showed that while privacy and security concerns have a negative impact on attitudes toward e-health portals, increasing the awareness of privacy and security controls alleviates such concerns. The findings also suggest that individuals worry more about who possesses the right to access their health data (i.e., who, what, when, and why) than the mechanisms used to safeguard data from unauthorized access. The study found that that perceived benefits and support (i.e., emotional and technical support) positively influenced the determinants of use intentions. The implications of these findings for health care providers and policy makers are discussed. For example, health care providers must explain the benefits of e-health portals to individuals adequately to increase their acceptance of e-health portals.

MULTIMORBIDITY FROM THE PERSPECTIVE OF COMPLEXITY SCIENCE

Another section of this issue of the newsletter discusses old age and loneliness. Closely related to those factors is the concept of multimorbidity, the occurrence of two or more long‐term conditions in an individual, which is a major global concern that places a huge burden on healthcare systems, clinicians, and patients. Multimorbidity challenges the current biomedical paradigm, in particular conventional evidence‐based medicine's dominant focus on single‐conditions. Patients' heterogeneous range of clinical presentations tend to escape characterization by traditional means of classification. Optimal management cannot be deduced from clinical practice guidelines. A paper in the October issue of the Journal of Evaluation in Clinical Practice argues that person‐focused care based in complexity science may be a transformational lens through which to view multimorbidity, to complement the specialism focus on each particular disease. Complexity science focuses on understanding, as a contextualized whole, the many parts of multifaceted phenomena. The approach offers an integrated and coherent perspective on an individual's living environment, relationships, somatic, emotional and cognitive experiences, and physiological function.

Providing this integration is an essential task of the generalist, but is it something that all clinicians need to be able to do when managing patients with multimorbidity? The underlying principles include non‐linearity; tipping points; emergence; importance of initial conditions; contextual factors and co‐evolution; and the presence of patterned outcomes. From a clinical perspective, complexity science has important implications at the theoretical, practice, and policy levels. Three essential questions emerge: (1) What matters to patients? (2) How can we integrate, personalize and prioritize care for whole individuals, given the constraints of their socio‐ecological circumstances? (3) What needs to change at the practice and policy levels to deliver what matters to patients? The authors acknowledge that these questions have no simple answers, but complexity science principles suggest a way to integrate understanding of biological, biographical, and contextual factors to guide an integrated approach to the care of patients who experience multimorbidity conditions. Managing these individuals simultaneously can have significant effects on health professionals themselves. It can challenge their: reductionist basic training; individual clinical and interpersonal competence; practice organization; interdisciplinary working styles; and last but not least, stress and burnout, especially when working with members of persistent chronic disadvantaged communities.