OBTAINABLE RESOURCES

Observing Race And Ethnicity Through A New Lens 

Survey questions about race and ethnicity can shed light on how experiences differ across groups and ultimately help policymakers and other interested parties address inequities in health and other outcomes. Yet, such questions often focus only on self-identified race and ethnicity and lump together diverse populations, masking substantial differences within groups and yielding results with insufficient nuance to understand and address inequities appropriately. A brief from the Urban Institute explores what can be learned by measuring race and ethnicity in alternative ways on surveys and what is missed by focusing only on one set of measures of these two factors. The assessment involves nonelderly adults’ perceptions of how others see their race based on their physical appearance (henceforth “street race”) and how responses to questions about street race vary depending on the response options given. The investigation proceeded by analyzing data from the December 2021 round of the Urban Institute’s Well-Being and Basic Needs Survey (WBNS), a nationally representative, internet-based study of adults ages 18 to 64. The brief can be obtained here.

What A Decline In Fertility Means For State Budgets 

Fertility continues to follow a downward trajectory across the U.S., falling to a record low in 2020. State budgets have started to feel the effects of this long-term decline and this historic drop will affect nearly every area of state budgets in the coming years. A brief from The Pew Charitable Trusts indicates that fewer births could yield cost savings. Many school districts are experiencing drops in enrollment and a sharp reduction in teenage pregnancies has helped limit growth in health expenditures. In the coming decades, however, governments may face resource challenges, with a smaller pool of workers likely suppressing income, sales, and other tax revenue sources. The historic decline in fertility will touch nearly every area of state budgets in the coming years. Some fiscal effects have already emerged, while others will be relatively minor or won’t be felt for decades. The implications for individual states vary. Those with shrinking workforces that rely more than other states on taxes sensitive to population declines—such as income and sales taxes—are especially vulnerable to budget pressures. Other demographic shifts, such as migration also will affect many sources of revenue and spending. Today, most states find themselves in a relatively healthy fiscal position, with many enjoying robust budget surpluses. Fewer births in recent years have contributed appreciable cost savings. If low fertility persists, however, states will need to look more for other ways to grow their tax bases or they could face challenges over the long term. The brief can be obtained here.

Families Caring For An Aging America

Family caregiving affects millions of Americans every day, in all walks of life. At least 17.7 million individuals in the United States are caregivers of an older adult with a health or functional limitation. The nation's family caregivers provide the lion's share of long-term care for our older adult population. They are also central to older adults' access to and receipt of health care and community-based social services. Yet the need to recognize and support caregivers is among the least appreciated challenges facing the aging U.S. population. Families Caring for an Aging America is a new publication from the National Academies of Sciences, Engineering, and Medicine. The document examines the prevalence and nature of family caregiving of older adults and the available evidence on the effectiveness of programs, supports, and other interventions designed to support family caregivers. This report also assesses and recommends policies to address the needs of family caregivers and to minimize the barriers that they encounter in trying to meet the needs of older adults. The report can be obtained here.

DEVELOPMENTS IN HIGHER EDUCATION

The U.S. Department of Education plans to hold a series of negotiated rule-making sessions in Spring 2023 to propose new rules. Topical areas include amending regulations on accreditation under the Higher Education Act of 1965, as amended (HEA), including rules associated with the standards relating to the Secretary’s recognition of accrediting agencies and accreditation procedures as a component of institutional eligibility for participation in Federal student financial aid. Secretary Miguel Cardona plans to amend regulations on state authorization as a component of institutional eligibility and also plans to propose to amend regulations that determine whether postsecondary educational programs prepare students for gainful employment in recognized occupations, and the conditions under which institutions and programs remain eligible for student financial assistance programs under Title IV of the Higher Education Act (HEA). Another proposal of interest is to amend the definition of distance education. A final set of regulations overhauling Title IX of the Education Amendments of 1972 is expected to occur in May.

The Biden administration has expressed strong interest in cancelling a portion of student debt. The     proposal would cancel as much as $10,000 in federal student debt for borrowers making under $125,000 a year, or $250,000 for a married couple. Recipients of Pell Grants would be entitled to an extra $10,000 of debt cancellation. Private loans, which make up less than 10% of all outstanding student debt, will not qualify unless they already had been consolidated into a federal loan. An obstacle to implementation occurred on November 14, 2022 when a three-judge panel of the Eighth U.S. Circuit Court of Appeals   issued a preliminary injunction to block the plan. The U.S. Supreme Court has entered the controversy by agreeing to decide whether student-loan debt relief for millions of Americans can go into effect. The Court became involved after Republican officials in six states claimed that the debt relief proposal was an unlawful exercise of presidential authority, which would affect state revenues and tax receipts. The matter is being decided by the justices on a fast-track timeline that may lead to a final ruling by the end of June 2023.

 Departments Of Education And Justice Filed A Legal Brief With The Supreme Court

The Biden administration remains committed to striving to deliver essential student debt relief to tens of millions of Americans. As part of this pledge, the Departments of Education and Justice filed a legal brief with the Supreme Court explaining the legal authority under the Higher Education Relief  Opportunities for Students Act to carry out a program of one-time, targeted debt relief. Department of Education Secretary Cardona stated that the purpose is to helping borrowers recover from the COVID-19 pandemic and providing working families with the breathing room they need to prepare for student loan payments to resume. As previously intended, student loan payments and interests will remain paused until the Supreme Court resolves the case because it is considered deeply unfair to ask borrowers to pay debt they wouldn’t have to pay, were it not for lawsuits viewed by the Administration as meritless.

 Rising Health Fees For College Students

Apropos of the topic of student educational debt, many families find it quite challenging to be able to    finance costs involving tuition, campus housing, meals, and activity fees. Another expense that can add to their anguish is rising health fees. Kaiser Health News discussed this issue in a report on December 19, 2022. Newly enrolled freshmen are discovering that it also is necessary to purchase both a student health insurance premium and a fee that allows them to access on-campus clinics and other services. The costs vary by school, but often can amount to several thousand dollars a year. The average for public colleges is $2,712 and $3,540 for private universities, according to a 2002 survey, but charges can be as high as $4,500 to more than $6,500, depending on the institution. Students can seek a waiver to university health insurance by showing they have their own coverage or are covered by a policy of their parents that meets specific university criteria. Some institutions, however, typically want to know that a student’s own insurance covers local doctors and hospitals for little out-of-pocket cost. 

117th CONGRESS DRAWS TO A CLOSE

Capitol Hill went into a lame duck session after the mid-term election in November 2022 in order to complete some important unfinished business of the 117th Congress. A significant achievement was to send an omnibus spending bill to President Joseph Biden that he signed into law (P.L.117-328) on December 29. The package will fund the federal government through September 2023. It  passed the Senate on a 68-29 vote and the House of Representatives by a vote of 225-201-1. Amounting to $1.7 trillion, it will provide funding for the rest of Fiscal Year 2023, which ends on September 30 of this year. The accomplishment compares well with events that unfolded  during the previous year. A spending agreement could not be reached until March 2022 for Fiscal Year 2022 that ended last September 30.

Weighing in at 4,155 pages, major features of P.L. 117-328 include a total of $209.9 billion (a $14.8 billion increase) for the Labor-HHS-Education account. Within that amount, the National Institutes of Health will receive a total of $47.5 billion and the Centers for Disease Control and Prevention will have $9.2 billion. The bill also contains $15.3 billion in bipartisan earmarks that will provide funding for some 7,000 congressionally-directed spending projects. Many of these endeavors will benefit higher education institutions.

Looking in the legislative rearview mirror, the 117th Congress drew to a close in December 2022. During its two calendar year lifespan, 24,784 measures were introduced that included bills, amendments, resolutions, joint resolutions, and concurrent resolutions. Of these total amounts, the House featured the introduction of 9,704 bills and the Senate 5,357 bills. Topically, in the House 1,292 bills pertained to health and 433 to education while in the Senate, 714 were in health and 220 in education.

Looking forward, the 118th Congress came into existence in January 2023. It differs from its predecessor in two fundamental ways. First, Democrats no longer will hold the majority in both chambers. Republicans now have a slight numerical edge in the House of Representatives. That party is headed by Kevin McCarthy, who succeeds Nancy Pelosi as House Speaker. Both individuals are part of the delegation from California. Another difference worth noting is that in the 118th Congress, women will make up more than a quarter (28%) of all members, the highest percentage in U.S. history and a considerable increase from where matters stood only a decade ago. Counting both the House and the Senate, women made up 153 of 540 voting and nonvoting members of Congress, representing a 59% increase from the 96 women who were serving in the 112th Congress a decade ago. A record 128 women are serving in the newly elected House, accounting for 29% of the chamber’s total. Of the 22 freshman representatives who are women, 15 are Democrats and seven are Republicans. In the Senate, women hold 25 of 100 seats, tying the record number they held in the 116th Congress.

REORIENTING U.S. HEALTH CARE

When considering health care both presently and in the future, two related facts are quite prominent. First, not only is the U.S. population steadily growing in size numerically, but the cohort of individuals ages 65 and older also is doing so at a faster rate proportionately. Accompanying that demographic transition is the fact that huge numbers of individuals who are part of this age group are characterized by having two or more chronic health problems that fuel a demand for health care and health-related social services.

Simultaneously, over the past several decades, health care increasingly has been conceptualized as a series of independent encounters (i.e., transactions) that can be distributed nearly randomly among health care personnel in the clinical setting, e.g., a physician can be on the other side of a telemedicine screen. According to an article in the December 2022 issue of the journal Mayo Clinic Proceedings, a transactional mindset exists that treats clinicians as interchangeable parts, which especially is problematic in specialties where continuity and longitudinal care play a critical role. Consequently, this industrial-based conceptualization has been harmful to health care and has impeded progress toward quadruple-aim outcomes: enhancing patient experience, improving population health, reducing costs, and improving the work life of health care providers.

Yet, such fragmentation of care is viewed as being ubiquitous. An example of structural pressures that deprioritize relationships is the adoption of models where care is provided separately by inpatient and outpatient personnel without creating time or incentives for them to coordinate with each other. If it is believed that intentionally reshaping operations, culture, technology, and financial incentives to prioritize relationships will benefit patients, clinicians, and payers who share in the costs of patient care, how can system transformation centered on relationships be accomplished?

The authors present three foundational actions that must be advanced to reorient the care delivery system: structurally prioritize continuity of relationships, make room for relationships by removing sludge from the system, and realign reimbursement and incentives at the delivery-system level. Examples of implementation strategies and tactics in each of these three domains are provided by the authors to guide organizational leaders, policy makers, technology vendors, and other interested parties.

One of the most fragile points of disjuncture within the health care system occurs at hospital discharge. In a system that radically is reoriented around relationships, the patient would not be discharged with the attendant risk of being unable to arrange necessary follow-up appointments or being seen by clinicians who lack information about the recent hospitalization. Instead, the patient would leave the hospital with actual appointments (date, time, and location) for all follow-up required to continue care safely. Systems would be built to communicate with the ambulatory clinic to arrange these appointments.

HEALTH REFORM DEVELOPMENTS

Apart from lacking insurance coverage to pay for health care costs, a related concern is that although some patients may be able meet such expenses, they reside in locations marked by serious health personnel shortages. Along with mental health services, dentistry represents that deficiency all too well. An inability to obtain dental care can lead to serious health problems that will result in more expensive interventions at a later time. According to the Health Resources and Services Administration (HRSA), 70 million individuals live in areas with a shortage of dental providers. Access especially is limited for those who receive their dental coverage through Medicaid, because it is estimated by the American Dental Association that approximately only 38% or about 75,000 of the 200,000 licensed dentists in the U.S. accepted that form of insurance. 

A challenge for dentistry is to expand the size of its health care team. A positive development is the inclusion of dental therapists, a group of licensed providers that work under the supervision of dentists to provide routine care involving dental exams and fillings. A problem is that they are authorized to work in only 13 states, but current efforts to expand their numbers in other states will make it possible to treat larger numbers of patients in different settings that include private practices and nursing homes. Higher education institutions have an important role to play in producing greater numbers of these essential practitioners.

National Health Spending

A decline in federal government spending led to more modest growth in health care expenditures in 2021, according to figures released in December 2022 by the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS). The 2021 National Health Expenditures (NHE) Report found that U.S. health care spending grew 2.7% to reach $4.3 trillion in 2021, slower than the increase of 10.3% in 2020. The slowdown was driven by a 3.5% decline in federal government expenditures for health care that followed strong growth in 2020 due to the COVID-19 pandemic response. This decline more than offset the impact of greater use of health care goods and services and increased insurance coverage in 2021. In 2021, the federal government and households accounted for the largest shares of national health spending (34% and 27%, respectively), followed by private businesses (17%), state and local governments (15%), and other private revenues (7%).

Health spending by major funds sources was as follows: Private Health Insurance (28% share) spending increased by 5.8% in 2021 to $1.2 trillion. Medicare (21% share) spending increased 8.4% to reach $900.8 billion in 2021, Medicaid (17% share) spending increased 9.2% to $734.0 billion in 2021, Out-of-Pocket (10% share) spending increased by 10.4% to $433.2 billion in 2021. Health care spending in 2021 for the largest three services—hospital care, physician and clinical services, and retail prescription drugs—was: Hospital Care (31% share) spending increased 4.4% in 2021 to reach $1.3 trillion, Physician and Clinical Services (20% share) spending increased 5.6% to $864.6 billion,    Retail Prescription Drugs (9% share) spending increased 7.8% to $378.0 billion in 2021, a faster rate than in 2020 when spending increased by 3.7%. The acceleration in growth was due to an increase in the use of prescription drugs in 2021.

New Medicare-Funded Residency Slots For Hospitals In Underserved Communities

The Centers for Medicare & Medicaid Services (CMS) on January 9, 2023 took a critical step to advance health equity and access to care, awarding the first 200 of 1,000 Medicare-funded physician residency slots to enhance the health care workforce and fund additional positions in hospitals serving underserved communities. Approximately three-quarters of the new positions will be for primary care and mental health specialties. The Fiscal Year 2022 Inpatient Prospective Payment System (IPPS) final rule established policies to implement new Medicare-funded physician residency slots to qualifying hospitals authorized by the Consolidated Appropriations Act, 2021, phasing in 200 slots per year over five years. In allocating these new residency slots, CMS prioritized hospitals with training programs in geographic areas demonstrating the greatest need for additional providers, as determined by Health Professional Shortage Areas. The first round of 200 residency positions awarded are for 100 teaching hospitals across 30 states, the District of Columbia, and Puerto Rico. They become effective on July 1 of this year.

A REVIEW OF AMISH HEALTH CONDITIONS AND SOCIAL MECHANISMS

Health researchers and service providers increasingly are interested in the Amish, a North American-based population whose rapid growth is occurring almost entirely in rural North America. In these rural locations, they have an outsized impact on local culture and infrastructure, both as they concentrate in existing communities and migrate to new places. Amishness refers to an ethnic group defined by a sense of shared history represented in part by a closed genetic pool of Swiss-German origin, a minority language, and a subjective sense of shared culture transmitted across generations and evident in, for example, ethnic and ancestral literature; ethnic enclaves and landscapes; insider-specific systems of symbols and meaning-making; and particular lifestyle-behavioral patterns. As an ethnic religion, the Amish are of interest to population health researchers due to a distinctive health profile arising from ethnic attributes, including a closed genetic pool and shared culture that shapes lifestyle practices. Amish-focused health research both furthers the knowledge base of health conditions by comparing Amish with non-Amish and assists health practitioners in serving this rapidly growing population.  

Amish health research is in need of review from the perspective of strengthening this knowledge body’s coherence, clarifying research directions, and identifying knowledge gaps, lapses, and stagnations. As described in the November 2022 issue of the journal Ethnicity & Health, researchers synthesize and discuss Amish physical health conditions research, both the population’s distinctive health profile and mechanisms shaping it. Specifically, they summarize research addressing body mass index (BMI), physical activity, and body image; diet and supplements; cancer; cardiovascular conditions; communicable diseases; immunity; sleep; genetic disorders; tobacco and alcohol use; periodontal conditions; traumatic injuries; natural treatments for burns; fertility; and sexually transmitted diseases. Upon reflection, questions are raised about the nature of intervening mechanisms shaping the Amish health profile, the strange omission of several common independent variables commonly used when studying other ethnic groups’ health, several recurring methodological complications, and public health policy considerations. A concluding thought is that because the Amish population is growing, any unresolved Amish-specific public health concerns will only increase. For example, they have a disproportionate share of individuals who reject many or all vaccinations. The possibility for vaccine-specific outbreaks will only grow (e.g., measles).

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Population-Level Trends In Adult Pain Treatments, 2011-2019

As reported in the December 2022 issue of the journal Archives of Physical Medicine and Rehabilitation, a study was conducted that included a comparison of the annual use of nonpharmacologic pain treatments versus prescription opioids among cancer-free adults. Other objectives were to estimate the annual use of acupuncture, chiropractic care, massage therapy, occupational therapy, and physical therapy; determine whether calendar year was associated with treatment type; and explore whether pain treatments varied by pain severity. The prevalence of nonpharmacologic treatments increased while prescription opioid use declined following policy and practice changes during the past decade. Nonpharmacologic pain treatments may be appropriate for all degrees of pain severity. Chiropractic care and physical therapy were the most common nonpharmacologic treatment providers. Nonpharmacologic treatments did not vary based on pain severity.

Severe Maternal Morbidity and Mortality Risk

Differences in rates of severe maternal morbidity and mortality (SMMM) have been studied among Medicaid-funded compared with privately insured hospital births through specific additive and intersectional risk by rural or urban geography; race and ethnicity; and clinical factors. Maternal discharge records from childbirth hospitalizations in the Healthcare Cost and Utilization Project's National Inpatient Sample from 2007 to 2015 were used. As reported in the November-December 2022 issue of the periodical Women’s Health Issues, the highest rate of SMMM (224.9 per 10,000 births) occurred among rural Indigenous Medicaid-funded births. Those births among Black rural and urban residents, and among Hispanic urban residents, also experienced elevated rates and significant additive interaction. These rates indicate an opportunity for tailored state and federal policy responses to address the particular maternal health challenges faced by Medicaid beneficiaries, including Black, Indigenous, and rural residents.

HEALTH TECHNOLOGY CORNER

Delivery Of Human Organ Transplantation By Drones

Organs are in short supply for patients in need of a life-saving transplant. The moment an organ is removed from the human body, it begins to deteriorate rapidly. Historically, organ transport has relied on standard ground and air transportation. Although these methods are satisfactory, they are risky, inefficient, and expensive. Significant delays persist and are exacerbated by road traffic and transportation availability in metropolitan areas. According to an article published on December 21, 2022 in the journal Science Robotics, researchers validated the process of donor lung transportation via remote piloted aircraft system (RPAS) in controlled airspace over a densely populated urban environment of downtown Toronto, Canada.  With the successful delivery of kidneys and now lungs, the development of a universal transport system for all organs is within reach. Thus, RPAS technology is likely to see early adoption in American Northeast, Southeast, and Ontario, Canada.

Applications Of Speech Analysis In Psychiatry

The need for objective measurement in psychiatry has stimulated interest in alternative indicators of the presence and severity of illness. Speech may offer a source of information that bridges the subjective and objective in the assessment of mental disorders. As reported in the January/February 2023 issue of the Harvard Review of Psychiatry, the utility of speech analysis depends on how accurately speech features represent clinical symptoms within and across disorders. Four domains of the application of speech analysis in the literature are: diagnostic classification, assessment of illness severity, prediction of onset of illness, and prognosis and treatment outcomes. Models that bring together multiple speech features can distinguish speakers with psychiatric disorders from healthy controls with high accuracy. Convergent progress in speech research and computer sciences opens avenues for implementing speech analysis to enhance objectivity of assessment in clinical practice.

OBTAINABLE RESOURCES

Global Roadmap For Healthy Longevity

With unprecedented global aging, societies must undertake all-of-society efforts to maximize the benefits and minimize the burdens of aging populations. The Global Roadmap for Healthy Longevity (Global Roadmap) describes a realistic vision of healthy longevity that could be achieved by 2050. The vision includes full inclusion of individuals of all ages, regardless of health or functional status, in all aspects of society and societies characterized by social cohesion and equity. To achieve the vision, Global Roadmap recommends changes that need to be made to health systems, social infrastructure, physical environments, education, work, and retirement. In some cases, the recommended changes benefit older persons most directly, but when the older portion of the population thrives, members of all ages benefit. If adopted and implemented, the recommendations of this report can support individuals of all ages in all corners of the globe to live long, meaningful, and purpose-driven lives by 2050. The report can be obtained here. 

Treating Older Patients In The Emergency Room 

AARP has teamed up with the Geriatric Emergency Department Collaborative (GEDC) to publish two new videos designed to educate and raise awareness about the serious issues of dementia and delirium in health care settings, particularly emergency rooms. These short educational resources provide action steps for providers, patients, and family caregivers to identify and manage issues related to brain health in the emergency room more effectively. By implementing relatively straightforward and cost-effective measures outlined in the videos, human brain health can be protected and medical outcomes can be improved. The videos are: 

· Dementia in the ED: Providing Better Care for Older ED Patients  

· Delirium in the Emergency Department: Serious, Costly, and Potentially Deadly 

They can be viewed here.  

Annual Report To The Nation On The Status Of Cancer 

Overall cancer death rates continued to decline among men, women, children, and adolescents and young adults in every major racial and ethnic group in the United States from 2015 to 2019, according to the latest Annual Report to the Nation on the Status of Cancer. From 2014 to 2018, overall cancer incidence, or new cases of cancer, remained stable for men and children, but increased for women and adolescents and young adults. This year’s report, published October 27, 2022, in the journal Cancer, also highlights longer-term trends in pancreatic cancer, as well as racial and ethnic disparities in incidence and death rates for many individual cancer sites. The report can be obtained here.  

Improving And Strengthening Employer-Sponsored Health Insurance 

Employer-sponsored insurance (ESI) represents the nation’s largest source of health coverage, but in-depth policy discussion on how to improve the employer system is lacking. With the current policy focus on Medicare, Medicaid, and the individual market, decision-makers are left wanting for ESI-dedicated proposals and analysis. Consequently, both employers and employees need solutions to improve ESI so it can remain in place for the foreseeable future. A new report from the Bipartisan Policy Center discusses this important topic and can be obtained here.

DEVELOPMENTS IN HIGHER EDUCATION

When faced with the daunting task of designing an effective structure for the U.S. government, the founders of this nation envisioned having a legislature to produce laws, a separate executive branch to implement those laws, and an independent judiciary to resolve any differences between them. For the most part, the arrangement functions reasonably well, but not always. An example is when the legislature is unable to reach agreement on a bill that is desired by the chief executive who occupies the White House. Whenever that situation arises, the result can best be described by President Obama who stated, “I've got a pen, and I've got a phone," thereby making it possible to issue executive orders to bypass congressional deadlock.  

It is an effective mechanism, but depending on the nature of that order and how contentious it is, the ruling may not have a long shelf life. For example, once a new president is elected from a different political party, that individual’s first actions might include rescinding a predecessor’s executive orders. A second remedy also is available by having a preliminary injunction granted, which occurred on November 14, 2022 by a three-judge panel of the Eighth U.S. Circuit Court of Appeals. That judicial decision blocks the Biden administration’s plan to cancel some student debt. According to U.S. Secretary of Education Miguel Cardona, as of mid-November 2022, more than 26 million borrowers have provided the information needed to process their applications for relief and 16 million applications have been approved and sent to loan servicers to be discharged when allowed by the courts. 

Time will tell whether students will reap the benefit of efforts to improve their financial situation. Focusing on the possibility that debt relief subsequently will go into effect, the U.S. Department of Education on October 31, 2022 released final regulations that streamline and improve the rules for major targeted debt relief programs. The regulations expand eligibility, remove barriers to relief, and encourage automatic discharges for borrowers who are eligible for loan relief because their school closed; they have a total and permanent disability; or their loan was falsely certified. The rules also establish a fairer process for borrowers to raise a defense to repayment, while preserving borrowers’ day in court by preventing institutions of higher education from forcing students to sign away their legal rights using mandatory     arbitration agreements and class action waivers. Finally, the rules help borrowers avoid spiraling student loan balances by eliminating all instances of interest capitalization not required by statute, which occur when unpaid interest is added to a borrower’s principal balance, increasing the total amount that may have to be paid.     

U.S. Supreme Court And College Admissions

The Supreme Court on August 31, 2022 heard several hours of oral arguments in two cases against Harvard University and the University of North Carolina that were brought by Students for Fair Admissions (SFFA) seeking to overturn four decades of precedent allowing the consideration of race in college admissions. Specifically, this group is petitioning justices to overturn a ruling in the case Grutter v. Bollinger, a decision in 2003 that enabled institutions of higher education to use race as part of a holistic review of admissions applications when narrowly tailored. The Court is expected to announce its decision in 2023, perhaps by early June.

Reauthorization Of The Higher Education Act (HEA)

The Higher Education Act of 1965 (P.L. 89-329, as amended), authorizes a broad array of federal student aid programs that assist students and their families with financing the cost of a postsecondary education, as well as programs that provide federal support to postsecondary institutions of higher education (IHEs). The Department of Education administers the programs authorized by the HEA. The most prominent components are the Title IV programs that provide financial assistance to students and their families. The HEA was first enacted in 1965 and has since been amended and extended numerous times. It has been comprehensively reauthorized eight times. The most recent comprehensive reauthorization occurred in 2008 for a five-year period. Whether it will be reauthorized in 2023 is uncertain. This newsletter will keep readers apprised of any developments that unfold.

HEALTH REFORM DEVELOPMENTS

The availability of high quality health care services is a key factor in producing satisfactory individual and community health status outcomes. A central role in achieving important objectives is played by the health workforce. A problem is that apart from medicine, few professions have data systems that make it possible to enumerate how many students are in the educational pipeline and how many qualified  personnel are in practice, which are determinations required to assess if the workforce matches the health care needs of patients. 

The Bureau of Health Professions (BHPr) in the Health Resources and Services Administration (HRSA) in the U.S. Public Health Service for many years in the 1980s and 1990s made important contributions to efforts aimed at producing an allied health workforce data system. An entity known as the Forum on Allied Health Data (FAHD) made it possible for data experts from several professions to gather annually to improve the collection and distribution of workforce information. The Association of Schools Advancing Health Professions (known as the Association of Schools of Allied Health Professions in the 1990s) hosted FAHD meetings and was awarded two federal contracts by the BHPr in that decade.  

One project was used to identify workforce data sources extant in federal government agencies (e.g., the Veterans Health Administration, Department of Defense, Indian Health Service, Bureau of Labor Statistics); state and city health departments; and professional organizations. A second project was aimed at developing a Minimum Data Set (MDS) that all of these sources could use to produce comparable kinds of information. The idea was to develop a system that reflected common data elements collected at similar periodic intervals. Unfortunately, that result never was achieved. Although the BHPr continues to receive federal appropriations, no funding is intended specifically for allied health workforce data considerations. Apart from a Bureau endeavor that enabled the Institute of Medicine to host an Allied Health Workforce and Services Workshop in 2011, related substantive efforts have lagged. 

National Health Care Quality And Disparities Report

On a related note, the Agency for Healthcare Research and Quality (AHRQ) has released its 2022 National Healthcare Quality and Disparities Report (NHQDR). It provides policymakers, health system leaders, and the public with a statistical portrait of how effectively the health care delivery system provides safe, high-quality, and equitable care to all Americans. The report’s “Portrait of American Healthcare” offers numerous important insights, including: life expectancy in the United States falls behind life expectancy in similarly developed countries, and the gap has grown since 1980; a shortage of primary care health professionals compromises access to services in more than 60% of U.S. counties; and social determinants of health may have a stronger influence on health outcomes than clinical services provided by health care delivery systems. 

Medicaid Structured Family Caregiving

The National Academy for State Health Policy (NASHP) has released a report, Medicaid Structured Family Caregiving: Enabling Family Members to Make Caregiving Their Primary Focus. This brief is based on research and interviews with state staff and examines how Georgia, Missouri, and South Dakota are using Medicaid-funded structured family caregiving (SFC) services to help older adults stay in their homes. These services consist of a package that supports a patient’s primary caregiver, including payment, training, coaching, respite care and other ingredients. Meanwhile, the QUICK STAT section of this November 2022 issue of TRENDS also has information about caregiver health status. 

Medicare Payment Advisory Commission (MedPAC)

MedPAC met virtually on November 3-4, 2022 to discuss a variety of policy issues, including aligning fee-for-service (FFS) payment rates across ambulatory settings, Medicare policy options for increasing payment to primary care providers, and differences in quality measure performance across Medicare populations. Commissioners analyzed quality measure results for different Medicare fee-for-service beneficiaries grouped by two social risk factors: race/ethnicity categories and income level. Moving forward, these officials will review and discuss the analyses and findings, and provide direction for   future work.

2022 ELECTION DAY ANTE- AND POSTMORTEM

Pundits were out in full force prior to the mid-term election on November 8, 2022. Emboldened by what some of them believed were preeminent concerns among voters, such as inflation, crime on the streets, and a southern border that is not secure, they enthusiastically predicted a “red wave” that would overwhelm Democrats in both the U.S. House of Representatives and the Senate. Unfortunately, these experts were not even close in their prognostications. Democrats not only survived, but even thrived in many states and congressional districts.

The eminent biologist J.B.S. Haldane suggested that there are four stages of acceptance in the advancement of science: 

· This is worthless nonsense. 

· This is an interesting and perverse point of view. 

· This is true, but quite unimportant. 

· I always said so. 

In the segment of the cognoscente known as political punditry, it did not take long after November 8 for the experts to change course rapidly to arrive at the equivalent of Haldane’s Stage 4. Not too surprisingly, they basically claimed to suspect well beforehand what the eventual outcome of the election would be. More importantly, rather than dwell on rear view mirror images, the main weighty intellectual task lies ahead, i.e., to predict what will happen in the upcoming 2024 presidential election by identifying who is going to run, who can win, and what the price of a pound of bananas will be on election day. 

ASAHP’s Executive Director, John Colbert, offered a detailed, comprehensive explanation on October 20, 2022 during a plenary session presentation at the Association’s Annual Conference regarding what to expect on election day—November 8. Not only did he provide forecasts that actually materialized, he also was able to look ahead at some ramifications of what to expect for the 2024 election. For example, one topic of particular interest to the health professions education community is reauthorization of the Higher Education Act (HEA). It was last reauthorized in 2008 for a five-year period.  

If legislative action is taken on the HEA in the 118th Congress that begins in 2023, it can be anticipated that the House and Senate will produce vastly different proposals, with the new House Republican majority focused on blocking the Administration’s proposal to cancel up to $20,000 in student loan debt for certain borrowers, as well as placing a cap on overall student borrowing, eliminating public service loan forgiveness, and requiring institutions to have “skin in the game,” holding them accountable for successful student outcomes. A narrowly divided Senate will require Democrats and Republicans to produce a bipartisan proposal, which in recent Congresses has proven elusive due to disagreements between the parties over both Title IV student financial aid, as well as Title IX protections.

RESOLVING HEALTH CARE AMBIGUITIES

Previous issues of this newsletter have discussed how an inability to arrive at correct definitions of various health disorders and how to diagnose them accurately will compromise the effectiveness of treatments that are administered. The October 2022 edition indicated that many scholars have noted that the concept of stigma is defined inconsistently throughout the literature, and that it is measured with different instruments. Similarly, the July-August 2022 issue pointed out that effectiveness in academic and clinical communication depends upon agreement on what words and concepts denote and on the consequent ability to argue logically and accurately. In the pain medicine literature, for example, unfortunately there are many examples of imprecision and confusion in this respect, including misnomers and fallacies in reasoning.

It is likely that readers of this newsletter at one time or another have experienced a headache. The entire August 2022 issue of the journal Seminars in Neurology is devoted to a discussion of this disorder. According to that publication, the first coherent headache classification is seen in writings dating back to the 1st century AD. More recently, the first significant modern attempt at classifying headache disorders was done by an ad hoc committee of the NIH in 1962. The system created that year relied on accepted ideas about headache diagnostic classes, including “vascular headaches” and “muscle contraction headaches.” Although there was little evidence for these categories, and the diagnostic definitions were vague, that “ad hoc committee” classification system was used worldwide for many years. Ultimately, its shortcomings were felt to be more of a barrier than an asset in developing a useful tool for both research and clinical needs.

Defining the epidemiology of headache disorders is challenging given the prevalence of stigma and other harmful misconceptions about these diseases. Understanding the widespread impact of such disorders is essential when considering social and policy interventions to mitigate their impact on health status. Tension-type headache still is considered the most common primary headache disorder, but population-based estimates of its prevalence vary widely. Migraine remains the most common headache disorder in patients who receive clinical care. Prevalence estimates have remained fairly stable over the last two decades, with a one-year period prevalence in the U.S. of 18% of women and 6% of men. Studies in the U.S. also show an inverse relationship between income level and migraine incidence and prevalence, particularly for chronic migraine. Factors mediating this relationship are difficult to define.

The burden of migraine is enormous. The Global Burden of Disease study indicates migraine is the number one cause of disability in women younger than 50 years of age and the number two or three cause of disability worldwide. Further study is needed into underdiagnosis, undertreatment, and persistent stigma associated with headache disorders, especially in underserved communities. Headaches constitute just one more health problem where more clarity and less ambiguity are needed.

DEVELOPMENTS IN HIGHER EDUCATION

Given the contentious nature of legislation that is enacted into law and also in rules finalized by agencies in the executive branch of the federal government, a plausible subheading for many of these initiatives might be “The Attorneys, Accountants, and Public Relations Organizations Relief Act of (fill in the year).” The government has developed an effective means of guaranteeing life-time job opportunities in the private sector for individuals willing to engage in this form of employment. For example, the deadline for submitting comments on a proposed rule to amend regulations implementing Title IX of the Education Amendments of 1972 closed on September 12, 2022. More than 235,000 were submitted. Just think of how many staff in commercial firms were involved in generating these comments on behalf of special interest group clients. Next, the Department of Education will review this huge volume of correspondence before releasing a final set of regulations. A companion thought worth pondering is how many Department personnel will need to be engaged in what can be expected to be a highly time-consuming operation of reviewing those Title IX comments. Whatever the eventual outcome, it is likely that the courts will be kept busy as opponents seek to have findings overturned.

If matters on the litigation front ever seem to become too quiescent, immediate assistance always is just a short distance away. As an illustration, on August 24, 2022 President Biden announced that he would cancel up to $10,000 in student debt for borrowers making under $125,000 a year, with up to $20,000 in relief for Pell Grant recipients. The U.S. Department of Education on September 29, 2022 released its estimate of the costs of this plan, indicating that it will cost an average of $30 billion a year over the next decade. The Administration points out that debt relief is designed to help borrowers and families most in need as they prepare to resume student loan payments in January 2023, with nearly 90% of relief dollars going to those earning less than $75,000 per year. Not surprisingly, opposition already is underway as lawsuits against the proposal are being filed. Among the concerns are that student debt relief will harm a state’s economy by reducing taxes collected and increasing inflation. On a more personal level, some individuals feel aggrieved because they already have worked diligently to pay off their educational debt and do not qualify for financial assistance while others who originally elected not to go to college view it as a handout at the expense of taxpayers.

 Primary Sources Of Tenure Track Faculty Members

Institutions of higher education in the U.S. hire most of their tenure-track faculty members from the same handful of elite institutions, according to a study published in the journal Nature on July 21, 2022. The finding suggests that prestige is overvalued in hiring decisions and that academic researchers have little opportunity to obtain jobs at institutions considered more elite than the ones at which they were trained. Specifically, the study reveals that just 20% of PhD-granting institutions in the United States supplied 80% of tenure-track faculty members to institutions across the country between 2011 and 2020. No historically Black colleges and universities (HBCUs) or Hispanic-serving institutions (HSIs) were among that 20%. One in eight U.S.-trained tenure-track faculty members obtained their PhDs from just five elite schools: the University of California, Berkeley; Harvard University; the University of Michigan in Ann Arbor; Stanford University; and the University of Wisconsin–Madison.

Exploring The Exodus From Higher Education

Enrollment in education after high school is falling significantly at a time when the economy is demanding more educated workers. It is important to understand why students are not attending or staying in college so that institutional leaders and policymakers can adopt policies and practices that meet more of the situations facing today’s students. HCM Strategists and Edge Research, on behalf of the Bill & Melinda Gates Foundation, were partners in conducting an in-depth analysis of current and former students’ attitudes about pursuing education after high school to understand better what is influencing these           students’ perceptions and plans regarding post-high school education. Among the major findings is that although dollars and debt are significant barriers, multiple factors affect this audience’s ability and interest in obtaining a degree. Individuals express limited life satisfaction, and many note they could not manage the stress/challenges associated with college. Addressing financial burdens alone is not a solution. 

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Numbers And Rates Of Suicide By Month And Demographic Characteristics: U.S., 2021

Suicide is a major contributor to premature death in the United States, especially among individuals aged 10 to 34, for whom it is the second leading cause of death. In this country, suicide increased 35% from 1999 to 2018 before declining by 5% through 2020. Despite the overall recent decline, rates continued to increase among females aged 10–24 and among males aged 10–44 and 75 and over. The increase in the number of suicides was greater for males (4%) than females (2%), with the provisional 2021 number for males (38,025) nearly four times that of females (9,621). According to a National Vital Statistics System Release in September 2022, provisional numbers of suicide by month in 2021 are reported and compared with final 2020 numbers, in total, and are presented by sex and age combined. Reporting of suicides in particular can be delayed because of investigations regarding the cause and circumstances surrounding the death. Rates for females are more likely to be incomplete because their deaths more frequently involve drug poisonings.

Associations Of Air Pollution With Body Size And Composition In Midlife Women

A study was done of longitudinal associations of air pollution exposure, including fine particulate matter, nitrogen dioxide, and ozone with weight, BMI, waist circumference, fat mass, lean mass, and proportion fat mass in midlife women. According to a description of research published on September 9, 2022 in the journal Diabetes Care, analyses provide evidence that exposure to these environmental factors is associated adversely with body composition, including higher fat mass, higher proportional fat mass, and lower lean mass, highlighting their potential contribution to obesity. In this prospective cohort study of 1,654 midlife women representing diverse racial/ethnic groups, exposure to air pollution was associated with adverse changes in body composition measures. In particular, particulate matter and nitrogen dioxide were associated positively with fat mass and proportion fat mass, and inversely associated with lean mass. Ozone was associated positively with proportion fat mass and inversely associated with lean mass.

HEALTH TECHNOLOGY CORNER

 Understanding Canine Diseases To Save Human Lives

Dogs develop diseases similar to those of humans. Their inbred genetics makes them a useful model for disease biology, allowing the development of new therapies for veterinary and human use. Inside the cancer center at the Virginia Tech Carilion Health Sciences and Technology campus, equipment, along with much of the building, is shared between veterinary patients and humans participating in clinical trials where dogs and humans can be treated side by side. According to an article published in the September 2022 issue of the journal Nature Medicine, dogs share the human environment and are prone to experiencing many of the same diseases as humans, which means that studying conditions, such as cancer in dogs can be used to develop new drugs for both species. Beyond tapping into the increasingly lucrative global veterinary medicine market (valued at U.S. $29.4 billion in 2021), researchers hope these efforts can improve the health of both pets and their human companions.

The Effect Of Expressive Writing On Wound Healing

Expressive writing is an intervention whereby individuals typically write for 20 minutes a day for three consecutive days about their deepest thoughts and emotions regarding a previous traumatic event or stressor. This activity has been found to be beneficial not only for self-reported health, psychological well-being, and general functioning, but also for immunological function. As described in a paper in the October 2022 issue of the Journal of Psychosomatic Research, investigators studied whether the content (expressive vs control) and timing (pre- vs post-wounding) of a writing task affect the activation of different cell types in the healing skin. The findings showed main effects of both timing and content, whereby those who wrote on either topic pre-wounding had a higher infiltration of Langerhans cells in the epidermis of the healing skin at day 14 compared to those who wrote post-wounding. These particular cells are critical for wound healing because they facilitate transitions between wound healing stages.

OBTAINABLE RESOURCES

Artificial Intelligence In Health Care

Each year, medical diagnosis errors affect the health of millions of Americans and cost billions of dollars. Machine learning technologies can help identify hidden or complex patterns in diagnostic data to detect diseases earlier and improve treatments. A report from the U.S. Government Accountability Office (GAO), the congressional watchdog agency, identified such technologies in use and development, including some that improve their own accuracy by learning from new data. Developing and adopting these technologies has challenges, however, such as the need to demonstrate real-world performance in diverse clinical settings. GAO policy options, like improving data access and collaboration, may help address challenges. Several machine learning (ML) technologies are available in the U.S. to assist with the diagnostic process. The resulting benefits include earlier detection of diseases; more consistent analysis of medical data; and increased access to care, particularly for underserved populations. GAO identified a variety of ML-based technologies for five selected diseases: certain cancers, diabetic retinopathy, Alzheimer’s disease, heart disease, and COVID-19 with most technologies relying on data from imaging such as x-rays or magnetic resonance imaging (MRI). These ML technologies have generally not been widely adopted. Academic, government, and private sector researchers are working to expand the capabilities of ML-based medical diagnostic technologies. The report can be obtained here.

National Strategy To Support Family Caregivers

A report that recently was released is entitled, the 2022 National Strategy to Support Family Caregivers. It provides detailed information about nearly 350 actions federal agencies will take over the next three years to support the nation’s 53 million family caregivers. The National Strategy includes more than 150 actions that state and local governments, public health departments, philanthropies, and community-based, faith-based, and nonprofit organizations should take, recognizing that all these groups have a fundamental role to play in supporting family caregivers. The National Strategy was created to support family caregivers of all ages, from youth to grandparents, and regardless of where they live or what caregiving looks like for them and their loved ones. It was developed jointly by the advisory councils created by the RAISE Family Caregiving Act (P.L. 115-119) and the Supporting Grandparents Raising Grandchildren Act (P.L. 115-196), with extensive input from the public, including family caregivers and the individuals they support. It will be updated in response to public comments and will evolve with the caregiving landscape. A 60-day comment period opened on October 1, 2022. The report and the opportunity to submit comments are here.

Accelerating The Use Of Findings From Patient-Centered Outcomes Research

Patient-centered outcomes research (PCOR) studies consider the questions and outcomes that are meaningful to patients to compare the effectiveness of different prevention, diagnostic, and treatment options. PCOR also increases patient involvement in their care by providing them an opportunity to evaluate the quality, outcomes, and effectiveness of health care treatments and interventions, especially in areas where there is poor existing clinical evidence. The National Academies of Sciences, Engineering, and Medicine Board on Healthcare Services hosted a series of public workshops to explore ways of accelerating the use of PCOR findings in clinical practice to improve health and health care. Workshop discussions touched on the role of community health workers in helping care providers see and understand the whole picture of patient lives, the need for community engagement to ensure research is conducted and applied to practice equitably, and ways of measuring the impact of efforts to disseminate and implement new practices based on PCOR. This report summarizes the discussions that took place at these workshops. The document can be obtained here.

NORMAL BLINDNESS: LOOKING BUT FAILING TO SEE

Looked But Failed to See (LBFTS) errors occur when observers fail to notice a clearly visible item. They can happen across a wide range of tasks and settings, from driving and medical image perception to laboratory visual search tasks, overlooking typos in a paper, or failing to see a cyclist in an intersection. LBFTS can be thought of as a form of “normal blindness.” Although obviously far less severe than clinical blindness, it is so universal that its costs are substantial at a societal level. An article published in the September 2022 issue of the journal Trends in Cognitive Sciences outlines a new, unified account of such errors, arguing that processes that function well in most situations are guaranteed to produce a steady stream of LBFTS errors under some circumstances. The authors advance the proposition that normal blindness is the by-product of the limited-capacity prediction engine that is the human visual system. Processes that evolved to allow individuals to move through the world with ease are virtually guaranteed to cause missing certain significant stimuli, especially in important tasks like driving and medical image perception.

Although various LBFTS situations may seem like distinct phenomena, it can be argued that based on recent work, they all can be seen as products of the same normal mechanisms of attention and object recognition. Specifically: (i) observers only select a subset of what they could process on each fixation (although they are not blind to the rest of the visual input); (ii) even the items that are selected by attention will be missed if too little time is given to their processing; (iii) the processes that give rise to routine visual awareness persuade us that we have seen more than we have actually seen; and (iv) attentional guidance (attentional set) can guide observers away from targets as well as toward them. Taken together, these factors produce a state of ‘normal blindness’ that has significant implications. A framework is shown in which multiple types of LBFTS errors arise from the same underlying processes. A relatively complex task is used in the form of a cartoon as an example. 

ETHICS AND EPISTEMOLOGY OF EXPLANATORY AI IN HEALTH CARE

Artificial Intelligence (AI) is believed to have the potential to produce radical changes in health care. Systems aim to improve diagnosis, prediction, and treatment of a wide array of health conditions. An assumption is that AI will enable more accurate and efficient ways to diagnose diseases and to restore the precious and time-honored connection and trust, i.e., the human touch, allowing health care professionals to spend more time with their patients. Meanwhile, according to a manuscript published in the December 2022 issue of the journal Ethics and Information Technology, sophisticated self-learning AI systems that do not follow predetermined decision rules, often referred to as black-boxes, have spawned philosophical debate. This black-box nature is believed to be a major ethical challenge for the use of these systems and it remains disputed whether explainability is philosophically and computationally possible.

Among various observations made, the authors point out that regarding the possibility of explanations of AI, there is a diversity of answers coming from the fields of computer sciences, philosophy, and the sciences (e.g., biology, medicine, chemistry). In the field of molecular biology, for instance, mechanistic explanations describing the behavior of the underlying mechanisms of real-world phenomena are standard. If the same explanatory logic is applied to AI, however, then it is much more difficult to uphold claims of genuine explanatory success. A claim is acknowledged that explanations of phenomena predicted by AI are unforthcoming due to the lack of causal relations underlying the model predictions. The problem stems from the fact that AI systems involve searching for (high) correlations between features in the data, but it is done without a theoretical backup to provide causal relations. Also, a concern has been expressed in a two-fold argument about a fully-automated explanation in the context of medicine. Medical AI delivers classifications, but classifications are not explanations. Additionally, an explanation requires a bona fide structure for that explanation. Reference also is made to many remaining questions that allude both to epistemologists and ethicists: Should explainability play a role, and if so, which role, in the responsible implementation of AI in medicine and healthcare?

HEALTH REFORM DEVELOPMENTS

A central aim of governmental efforts to improve individual and community health status in the U.S. is to remove inequities. Many kinds of social determinants influence the extent to which all segments of the population benefit from having equal access to high quality health care services. One factor affecting the ability to obtain services has to do with one’s residential location. For example, a  report issued in September 2022 from the American Hospital Association highlights the variety of  causes that resulted in 136 rural hospital closures from 2010 to 2021, and a record 19 closures in 2020 alone. Many longstanding pressures are involved, such as low reimbursement, staffing shortages, low patient volume, and regulatory barriers, as well as the continued financial challenges associated with the COVID-19 pandemic. The report outlines several pathways for rural hospitals to achieve financial sustainability, including additional federal support, flexible models of care, decreased regulatory  burden, partnership arrangements, and state Medicaid expansion. The AHA also continues to urge Congress to extend the Medicare-dependent Hospital and enhanced Low-volume Adjustment programs, which are set to expire this month. The programs provide vital support for geographically isolated rural hospitals with low patient volumes.  

Apart from having accessibility to hospitals, other examples can be provided about unequal use of health care services. A data brief from the Office of the Inspector General at the Department of Health and Human Services (HHS) in September 2022 reveals that the COVID-19 pandemic created unprecedented challenges for how Medicare beneficiaries access health care. The Centers for Medicare & Medicaid Services (CMS) took a number of actions to expand access to telehealth for Medicare beneficiaries temporarily. More than 28 million, about two in five, Medicare beneficiaries used telehealth during the first year of the pandemic. CMS increased the types of services that beneficiaries could use via telehealth, from 118 to 264 service types. Beneficiaries in urban areas were more likely than those in rural areas to use telehealth. In total, 45% of beneficiaries in urban areas used telehealth during the first year of the pandemic. They accounted for more than 24 million of the 54 million Medicare beneficiaries living in urban areas. In contrast, just 33% percent of beneficiaries in rural areas used telehealth. They accounted for more than three million of the more than 11 million Medicare beneficiaries living in rural areas. Reasons for this disparity pertain to rural populations being less likely than residents in urban areas to have access to broadband connectivity. Rural health care providers also may face challenges providing telehealth to their patients because equipment and internet connectivity can be too expensive. 

Poverty And Health Insurance Coverage

The U.S. Census Bureau announced on September 13, 2022 that real median household income in 2021 was not statistically different than 2020. The official poverty rate of 11.6% also was not statistically different between 2020 and 2021. The Supplemental Poverty Measure (SPM) rate in 2021 was 7.8%, a decrease of 1.4 percentage points from 2020. Meanwhile, the percentage of individuals with health insurance coverage for all or part of 2021 was 91.7% (compared to 91.4% in 2020.) An estimated 8.3% of the population, or 27.2 million, did not have health insurance at any point during 2021, according to findings from the 2022 Current Population Survey Annual Social and Economic Supplement (CPS ASEC). That amount compared with an estimated 8.6% of the population, or 28.3 million, who did not have health insurance at any point during 2020. In 2021, private health insurance coverage continued to be more prevalent than public coverage, at 66.0% and 35.7%, respectively. Some individuals may have more than one coverage type during the calendar year. Of the subtypes of health insurance, employer-based insurance was the most common, covering 54.3% of the population for some or all of the  calendar year. 

Constitutionality Of Affordable Care Act Continues To Foster Litigation

A federal judge in Texas agreed this month with plaintiffs that requiring insurers to cover the costs of medications for HIV pre-exposure prophylaxis (PrEP) infringed on their religious rights, effectively eliminating a central tenet of the Affordable Care Act (ACA). Under the ACA, most health plans are required to pay for a range of preventive services. The decision came in response to Braidwood Management v. Becerra (formerly Kelley v. Becerra). Plaintiffs argued that the ACA requirement for insurers to pay for certain preventive services was unconstitutional, because it encouraged behavior that clashed with their personal and religious beliefs, such as  services related to reproductive and sexual health.

OBTAINABLE RESOURCES

Addressing Structural Racism, Bias, And Health Communication Regarding Obesity

The National Academies of Sciences, Engineering, and Medicine's Roundtable on Obesity Solutions convened a three-part workshop series that explored how structural racism; weight bias and stigma; and health communication intersect with obesity, gaps in the evidence base, and challenges and opportunities for long-term, systems-wide strategies needed to reduce the incidence and prevalence of obesity. Through diverse examples across different levels and sectors of society, the workshops explored how to leverage the connections between these three drivers and innovative data-driven and policy approaches to inform actionable priorities for individuals, organizations, and policymakers to make lasting systems change. The workshop report can be obtained at

Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series |The National Academies Press.

The Demographic Outlook: 2022 To 2052

The size of the U.S. population and its age and sex composition affect federal spending, revenues, deficits, debt, and the economy. In a new report, the Congressional Budget Office (CBO) describes its population projections that underlie the baseline budget projections and economic forecast that CBO published in May 2022 and the long-term budget projections that the agency published in July 2022. In CBO’s projections, the population increases from 335 million individuals in 2022 to 369 million in 2052, expanding by 0.3% per year, on average. (In this report, population refers to the Social Security area population—the relevant population for the calculation of Social Security payroll taxes and benefits. The population also is projected to become older, on average, as growth in the number of individuals age 65 or older outpaces that of younger age groups. The civilian noninstitutionalized population grows in numbers in CBO’s projections, from 264 in 2022 to 298 million in 2052. (This measure of the population includes only individuals age 16 or older. The agency uses it to project the size of the labor force.) The prime working age population (ages 25 to 54) grows at an average annual rate of 0.2% over that period, slower than its average over the 1980–2021 period (1.0%). In CBO’s current projections, the population is smaller and grows more slowly, on average, than CBO projected last year. Fertility rates are expected to be lower than the agency projected last year, reducing the size and growth of the population that is under 24 years old over the 30-year projection period. The report can be obtained at

https://www.cbo.gov/system/files/2022-07/57975-demographic-outlook.pdf.

Innovating Undergraduate Education: Lessons From The Pandemic

Innovating undergraduate education must take into consideration the current expectation among college-bound high school students of a return to the traditional. Simply stated, after the challenges of build-the-airplane-while-you-fly-it remote learning and all its attendant problems, students are expecting a return to the face-to-face education of yesteryear.  According to the firm Eduventures, however, the United States is at an inflection point with traditional-aged undergraduate education: Either it is possible to breathe a post-pandemic sigh of relief and go back to an undergraduate education steeped in tradition and circumscribed by the campus and its in-person interactions or a leap can be made to reinvigorate undergraduate education by innovating the experience based on pandemic learnings. The company believes that the latter will help higher education institutions provide relevant education for tomorrow’s so-called “traditional undergraduates.” Ye,t truly innovating undergraduate education requires a considered examination of what pandemic-related technology and pedagogy worked and didn’t work. It also requires a demonstration of value to students who currently yearn for tradition. More information can be obtained at Innovating Undergraduate Education: Lessons from the Pandemic (encoura.org)

HEALTH REFORM DEVELOPMENTS

A central aim of governmental efforts to improve individual and community health status in the U.S. is to remove inequities. Many kinds of social determinants influence the extent to which all segments of the population benefit from having equal access to high quality health care services. One factor affecting the ability to obtain services has to do with one’s residential location. For example, a  report issued in September 2022 from the American Hospital Association highlights the variety of  causes that resulted in 136 rural hospital closures from 2010 to 2021, and a record 19 closures in 2020 alone. Many longstanding pressures are involved, such as low reimbursement, staffing shortages, low patient volume and regulatory barriers, as well as the continued financial challenges associated with the COVID-19 pandemic. The report outlines several pathways for rural hospitals to achieve financial  sustainability, including additional federal support, flexible models of care, decreased regulatory  burden, partnership arrangements and state Medicaid expansion. The AHA also continues to urge    Congress to extend the Medicare-dependent Hospital and enhanced Low-volume Adjustment programs, which are set to expire this month. The programs provide vital support for geographically isolated rural hospitals with low patient volumes. 

Apart from having accessibility to hospitals, other examples can be provided about unequal use of health care services. A data brief from the Office of the Inspector General at the Department of Health and Human Services (HHS) in September 2022 reveals that the COVID-19 pandemic created unprecedented challenges for how Medicare beneficiaries access health care. The Centers for Medicare &   Medicaid Services (CMS) took a number of actions to expand access to telehealth for Medicare beneficiaries temporarily. More than 28 million, about two in five, Medicare beneficiaries used telehealth during the first year of the pandemic. CMS increased the types of services that beneficiaries could use via telehealth, from 118 to 264 service types. Beneficiaries in urban areas were more likely than those in rural areas to use telehealth. In total, 45% of beneficiaries in urban areas used telehealth during the first year of the pandemic. They accounted for more than 24 million of the 54 million Medicare beneficiaries living in urban areas. In contrast, just 33% percent of beneficiaries in rural areas used telehealth. They accounted for more than 3 million of the more than 11 million Medicare  beneficiaries living in rural areas. Reasons for this disparity pertain to rural populations being less likely than residents in urban areas to have access to broadband connectivity. Rural health care providers also may face challenges providing telehealth to their patients because equipment and internet connectivity can be too expensive.

Poverty And Health Insurance Coverage

The U.S. Census Bureau announced on September 13, 2022 that real median household income in 2021 was not statistically different than 2020. The official poverty rate of 11.6% also was not statistically   different between 2020 and 2021. The Supplemental Poverty Measure (SPM) rate in 2021 was 7.8%, a decrease of 1.4 percentage points from 2020. Meanwhile, the percentage of individuals with health   insurance coverage for all or part of 2021 was 91.7% (compared to 91.4% in 2020.) An estimated 8.3% of the population, or 27.2 million, did not have health insurance at any point during 2021, according to findings from the 2022 Current Population Survey Annual Social and Economic Supplement (CPS ASEC). That amount compared with an estimated 8.6% of the population, or 28.3 million, who did not have health insurance at any point during 2020. In 2021, private health insurance coverage continued to be more prevalent than public coverage, at 66.0% and 35.7%, respectively. Some individuals may have more than one coverage type during the calendar year. Of the subtypes of health insurance, employer-based insurance was the most common, covering 54.3% of the population for some or all of the  calendar year.

Constitutionality Of Affordable Care Act Continues To Foster Litigation

A federal judge in Texas agreed this month with plaintiffs that requiring insurers to cover the costs of medications for HIV pre-exposure prophylaxis (PrEP) infringed on their religious rights, effectively eliminating a central tenet of the Affordable Care Act (ACA). Under the ACA, most health plans are required to pay for a range of preventive services. The decision came in response to Braidwood Management v. Becerra (formerly Kelley v. Becerra). Plaintiffs argued that the ACA requirement for insurers to pay for certain preventive services was unconstitutional, because it encouraged behavior that clashed with their personal and religious beliefs, such as  services related to reproductive and sexual health.