QUICK STAT (SHORT, TIMELY, AND TOPICAL

Maternal Mortality Rates In The United States: 2021

A March 2023 report from the National Center for Health Statistics indicates that in 2021, 1,205 women died of maternal causes in the United States compared with 861 in 2020 and 754 in 2019. The maternal mortality rate for 2021 was 32.9 deaths per 100,000 live births, compared with a rate of 23.8 in 2020 and 20.1 in 2019. In 2021, the maternal mortality rate for non-Hispanic Black (subsequently, Black) women was 69.9 deaths per 100,000 live births, 2.6 times the rate for non-Hispanic White (subsequently, White) women (26.6). Rates for Black women were significantly higher than rates for White and Hispanic women. The increases from 2020 to 2021 for all race and Hispanic-origin groups were significant. Rates increased with maternal age. In 2021, they were 20.4 deaths per 100,000 live births for women under age 25, 31.3 for those aged 25–39, and 138.5 for those aged 40 and over. The rate for women aged 40 and over was 6.8 times higher than the rate for women under age 25.  

Prevalence And Characteristics Of Autism Spectrum Disorder Among Children Aged Eight Years

Data from the March 24, 2023 issue of the Morbidity and Mortality Weekly Report show that for 2020, across all 11 Autism and Developmental Disabilities Monitoring sites, Autism Spectrum Disorder (ASD) prevalence per 1,000 children aged eight years ranged from 23.1 in Maryland to 44.9 in California. The overall ASD prevalence was 27.6 per 1,000 (one in 36) children aged eight years and was 3.8 times as prevalent among boys as among girls (43.0 versus 11.4). Overall, ASD prevalence was lower among non-Hispanic White children (24.3) and children of two or more races (22.9) than among non-Hispanic Black or African American (Black), Hispanic, and non-Hispanic Asian or Pacific Islander (A/PI) children (29.3, 31.6, and 33.4 respectively). ASD prevalence among non-Hispanic American Indian or Alaska Native (AI/AN) children (26.5) was similar to that of other racial and ethnic groups. ASD prevalence was associated with lower household income at three sites, with no association at the other sites.  

HEALTH TECHNOLOGY CORNER 

Breast Cancer Prevention And Screening Recommendations Provided By ChatGPT

Researchers at the University of Maryland School of Medicine in February 2023 created a set of 25 questions related to advice on obtaining screened for breast cancer. They submitted each question to ChatGPT three times to see what responses were generated. ChatGPT provided appropriate responses for most (88%) questions posed about breast cancer prevention and screening as assessed by fellowship-trained breast radiologists. It gave one inappropriate recommendation regarding scheduling mammography in relation to COVID-19 vaccination. Inconsistent responses were found for two questions about breast cancer prevention and screening locations. Although clinically appropriate, recommendations related to screening mammography referenced American Cancer Society guidelines, without mention of the American College of Radiology or the United States Preventive Services Task Force. A description of the study was published on April 4, 2023 in the journal Radiology. 

Gene Editing To Prevent Ventricular Arrhythmias

Human pluripotent stem cell-derived cardiomyocytes (hPSC-CMs) offer a promising cell-based therapy for myocardial infarction, however, the presence of transitory ventricular arrhythmias, termed engraftment arrhythmias (EAs), hampers clinical applications. According to an article published on April 6, 2023 in the journal Cell Stem Cell, researchers at the University of Washington School of Medicine in Seattle have engineered stem cells that do not generate dangerous arrhythmias, a complication that has to date thwarted efforts to develop stem-cell therapies for injured hearts. To create their therapeutic heart cells, the Seattle researchers used pluripotent stem cells. Unlike adult stem cells, which have specialized to become specific cell types, pluripotent stem cells can become any type of cell in the body. From 2012 to 2018 the Seattle team successfully injected pluripotent stem cells into damaged heart walls to create new muscle to replace that lost during an infarction. In animal studies, they showed that the grafted cells would integrate with the heart muscle, beat in synchrony with the other heart cells, and improve the heart’s contractility.  

HEALTH REFORM DEVELOPMENTS

Another item in this month’s issue of the ASAHP newsletter highlights the importance that data play in developing effective health policy. Data from the jointly administered federal-state Medicaid program frequently are used to investigate racial and ethnic disparities in health. Unfortunately, there is         considerable variation in the completeness of such information across the United States. For example, according to the U.S. Census Bureau, about 19% of Medicaid beneficiaries were missing race/ethnicity information, a rate that varies considerably across states. Approximately one-third of states (18) were missing less than 10% of beneficiaries’ race/ethnicity information. Three states (Nebraska, Rhode Island, and Tennessee) did not have race/ethnicity information for any of their Medicaid beneficiaries.  

To address these gaps, the U.S. Census Bureau’s Enhancing Health Data (EHealth) Program assessed the feasibility, benefit, and effectiveness of linking Medicaid enrollment data (T-MSIS) with Census Bureau microdata (i.e., Decennial Census, American Community Survey (ACS), Census Numident) to enable researchers to document and track racial/ethnic disparities in health more effectively. Also, this research evaluated whether and to what degree bias was introduced into mortality estimates when Medicaid beneficiaries with missing race/ethnicity information were omitted from analysis. Results demonstrate significant potential for using Census Bureau data to complement existing health records that commonly lack important demographic characteristics, such as race/ethnicity. Overall, enhancing this information in Medicaid data with restricted Census Bureau microdata is feasible and can advance an understanding of population health. 

Growth In Health Care Costs

In 2020, lower use of health care services led to the first decline in per person health care spending that was seen in 12 years. That decline in utilization, however, was concentrated in the early months of the pandemic. By mid-2020, data from a report in April 2023 from the Health Care Cost Institute, a research group that has partnerships with insurers (CVS Health/Aetna, Humana, and Blue Health Intelligence ) to gauge the health care market, show that use (and spending) had largely returned to pre-pandemic levels. In 2021, there was a full rebound in per person health care spending, which was nearly $6,500 (15% higher than in 2020). A 13% increase in utilization from 2020 to 2021 contributed to this growth, following the 7.5% decline in use in 2020. Average prices grew 2% from 2020 to 2021. This lower growth rate than in previous years reflects that the overall mix of care was less expensive in 2021 than in 2020 when many lower cost preventive services were delayed. Overall, prices grew close to 14% over the 2017-2021 period while use grew just over 7%. The largest growth in prices was for inpatient hospital services, which grew 28% even as use declined over the five–year period. Growth in health care prices, and particularly in hospital prices, remains a persistent challenge to access and affordability.  

The Risk Of Losing Health Insurance

Health insurance coverage in the United States is highly uncertain. In the post-Affordable Care Act (ACA), pre-COVID period, it is estimated that while 12.5% of individuals under 65 are uninsured at a point in time, twice as many are uninsured at some point over a two-year period. Moreover, the risk of losing insurance remained virtually unchanged with the introduction of the landmark ACA according to an article in the May 2, 2023 issue of the journal Proceedings of the National Academy of Sciences of the USA. Data from the Medical Expenditure Panel Survey were used that cover the time period after the landmark Affordable Care Act (ACA) and before the COVID-19 pandemic—from 2014 to 2019—as well as the period 2007 to 2013 prior to the ACA.   

Risk of insurance loss is particularly high for those with health coverage through Medicaid or private exchanges. They have a 20% chance of losing coverage at some point over a two-year period, compared to 8.5% for those with employer-provided coverage. Individuals who lose insurance can experience prolonged periods without coverage. Approximately one-half of them still are uninsured six months later. Almost one-quarter are uninsured for the subsequent two years. Health insurance coverage, whose purpose is to provide a measure of certainty in an uncertain world, is itself highly uncertain. The risk of losing it reduces its value for risk-averse individuals. It also creates the potential for suboptimal medical choices as individuals suboptimally may shift the timing of their medical treatments to align with when they have insurance coverage. 

TECHNOLOGY AND HEALTH CARE

Technological developments have left an enormous imprint on major health care factors, such as cost, quality, and access by patients. A current topic of significant importance is the realm of activity known as artificial intelligence (AI). The various uses of AI in medicine have been expanding rapidly in many areas, including in the: analysis of medical images, detection of drug interactions, identification of high-risk patients, and coding of medical notes. Several such uses are topics in the “AI in Medicine” review article series that had its debut in the March 30, 2023 issue of the New England Journal of Medicine. An aim of the series is to cover progress, pitfalls, promise, and promulgation at the interface of AI and medicine. As a further commitment, a new journal, NEJM AI, will be launched in 2024 to provide a forum for high-quality evidence and resource sharing for medical AI, along with informed discussions of its potential and limitations. 

As a consequence of a substantial investment of money and intellectual effort, computer reading of electrocardiograms (ECGs) and white-cell differential counts; analysis of retinal photographs and cutaneous lesions; and other image-processing tasks has become a reality. Many of these machine-learning–aided tasks have been largely accepted and incorporated into the everyday practice of medicine while the use of AI and machine-learning in medicine has expanded beyond the reading of medical images. AI and machine-learning programs have entered medicine in ways that include, but not limited to, helping to identify outbreaks of infectious diseases that may have an influence on public health; combining clinical, genetic, and many other laboratory outputs to identify rare and common conditions that might otherwise have escaped detection; and aiding in hospital business operations. 

As noted in the NEJM, the use of AI and machine-learning already has become accepted medical practice in the interpretation of some types of medical images, such as plain radiographs, computed tomographic (CT) and magnetic resonance imaging (MRI) scans, and skin images. For these applications, AI and machine-learning have been shown to help health care providers by flagging aspects of images that deviate from the norm. A key question becomes what is the norm? This simple query reveals one of the weaknesses of the use of AI and machine-learning in medicine as it is largely applied today. 

Key concerns requiring a much deeper understanding include how bias in the way AI and machine-learning algorithms were “taught” influence how they function when applied in the real world? How can human values be interjected into AI and machine-learning algorithms so that the results obtained reflect the real problems faced by health professionals? What issues must regulators address to ensure that AI and machine-learning applications perform as advertised in multiple-use settings? How should classic approaches in statistical inference be modified, if at all, for interventions that rely on AI and machine-learning? These problems are among the many that must be confronted. The “AI in Medicine” series can be expected to address these kinds of matters. 

CRIMINAL RECORDS AND ALLIED HEALTH LICENSURE

Fully 20%–25% of jobs in the United States now require a state-issued license, but the percentage is closer to 75% in the one-fifth of the US economy that is devoted to health care, according to a manuscript published in the April 2023 issue of the Journal of Health Politics, Policy & Law. Since a license is required for many occupations in health care, restrictions on applicants with criminal records can foreclose substantial employment. Also, to the extent that occupational licensing restrictions affecting allied health professions (AHPs) prevent workers from marginalized groups from securing better jobs and economic opportunities, they have the potential to entrench economic and racial inequality. Researchers examined how 12 representative states (California, Colorado, Connecticut, Delaware, Florida, Illinois, Missouri, New York, Ohio, Pennsylvania, South Dakota, and Texas) handle applicants with criminal records. The focus was on five entry-level AHPs (dental hygienist, occupational therapy assistant, physical therapy assistant, respiratory therapist, and radiologic technologist).  

The data set covers 24% of the U.S. states and 50% of the U.S. population. All 12 states license four of the five AHPs (dental hygienist, occupational therapy assistant, physical therapy assistant, and respiratory therapist), and a majority of those states (8 of 12) license the fifth AHP (radiologic technologist). Every state requires consideration of whether an applicant for a license has a criminal record, and each state provides a list of categorical and discretionary exclusion criteria. About half the states limit the scope of discretionary exclusions to convictions that are related substantially to the scope of services in the AHP, but the other half do not have such restrictions. Only three of the 12 states prohibit their licensing boards from evaluating “moral character” when evaluating licensing applicants. A combination of dynamics seems likely to deter individuals with a criminal record from even considering entering an AHP. Because the likelihood of having a criminal record is not uniform across the population, excluding applicants with a criminal record seems likely to have a disparate impact across various subpopulations (principally race and gender) and has the potential to affect health equity.

THE ROLE OF EMPATHY IN QUALITY HEALTH CARE

Satisfactory patient care is a core component of quality health care. A positive care experience has occurred when patients report that they experienced what they desired during their interactions with care providers and the system, for example, respectful communication, coordinated care, and timeliness. Positive patient experiences also are important because they are associated with other desirable outcomes, including greater patient adherence to treatment recommendations, better health outcomes, less unnecessary health care utilization, higher staff satisfaction, and better financial performance. As reported in the April 2023 issue of the journal Health Services Research, despite these acknowledged benefits many adults in the United States who visited a doctor report undesirable care experiences. Furthermore, analyses of Centers for Medicare and Medicaid data in 2022 show that only 6% (178) of 3121 hospitals received the highest score of five stars for patient experience. Moreover, this experience particularly is poor for members of minority groups with Black and Hispanic patients relative to Whites having lower scores for person-centered care (26% and 29% of measures lower, respectively) and care coordination (73% and 44% lower, respectively). 

Increasingly, empathy, i.e., understanding and responsiveness to others' thoughts and emotions, is being discussed as a critical contributor to patient experience and patient-centered care. Research on this topic in health care has investigated what facilitates and hinders it, its outcomes, how to measure it, who is (un)likely to display it, and how to improve it. Investigations have produced a large field of information. Unfortunately, it has remained disjointed with little summarizing or integrative work to date, limiting clarity about predictors, outcomes, gaps, opportunities, and intervention effectiveness. A study is described in the aforementioned journal of a systematic review of research on empathy that provides an integrative summary of what is known about predictors and consequences of empathy, methods to study it, and interventions targeting it. The review indicates most studies are survey-based and cross-sectional, empathy predicts health care goals (better outcomes), and five factors predict empathy: provider demographics, characteristics, and behaviors; target characteristics; and organizational context. Analysis of interventions to improve empathy suggests that it can be increased at the individual level via education, but evidence is lacking on organizational-level interventions.

STATE-LEVEL TRENDS IN LIFESPAN VARIABILITY IN THE U.S.

Genetic codes play a highly influential role in human morbidity and mortality, while a case can be made that zip codes also must be taken into account. Where individuals reside has important consequences for their health and well-being. Geographic areas of the U.S. vary on several social, economic, and political dimensions associated with mortality risk. According to an article published in the February 2023 issue of the journal Demography, states are of particular interest because they are semiautonomous units whose governments exert considerable influence over the implementation of policies regarding social service programs and healthcare delivery. Compositional and contextual differences by state contribute to geographic disparities in mortality risk in the United States that are wide, persistent, and potentially growing. For example, life expectancy in 2019 ranged from a high of 80.9 years in Hawaii to a low of 74.4 years in Mississippi. This wide discrepancy among U.S. states exceeds the range in life expectancy among high-income nations. The extent to which differences in lifespan variability by state have changed over time, however, is unclear.  

The study referred to in the aforementioned journal article indicates that lifespan variability declined over time for all states, but sizable disparities remain between states. These differences generally align with states' varied demographic, cultural, and socioeconomic contexts. For instance, southern and Appalachian states experience higher levels of poverty and poor health than other parts of the country. These states exhibit persistently higher levels of lifespan variability. Additionally, states vastly differ in their policy contexts regarding social inequality, such as Medicaid expansion, Earned Income Tax Credit, tobacco control, and setting a minimum wage above the federal level. Policies that alleviate poverty and promote educational and occupational opportunities may be especially effective for averting preventable, early-life deaths that contribute disproportionately to lifespan variability. State policies that curtail early-life mortality would have the dual benefit of increasing life expectancy while simultaneously decreasing lifespan inequality. By adopting more progressive policies found in most low-variability states, high-variability states have the potential to extend the lives of their most vulnerable residents, reduce lifespan variability, and close the population health gaps between the leading and lagging states. Although more research is needed to identify the reasons behind increases in lifespan variability, evidence suggests that rising accidental poisoning and suicide deaths among younger adults are contributing factors.

OBTAINABLE RESOURCES

Genomics Across The Continuum Of Precision Health Care

The National Academies Roundtable on Genomics and Precision Health, in collaboration with the National Cancer Policy Forum, hosted a public workshop that examined how genomic data are used in health care, outside of the traditional settings for clinical genetics. The workshop identified opportunities for advancement of precision health care delivery. The event also explored how patients, clinicians, and payers assess and act upon the risks and benefits of genomic screening and diagnostic testing. Discussions focused on strategies to ensure that genomic applications are responsibly and equitably adopted to benefit populations as well as individuals over time. This Proceedings of a Workshop summarizes content from the event. They can be obtained at Realizing the Potential of Genomics across the Continuum of Precision Health Care: Proceedings of a Workshop |The National Academies Press.

 Clinical Ethics In Revised Hospital Accreditation Standards

An article published on March 24, 2023 by The Hastings Center indicates that it is remarkable that in the wake of Covid-19 and all the ethical challenges and health care inequities associated with the pandemic, The Joint Commission, which accredits U.S. hospitals, eliminated the sole element of performance that governed clinical ethics services: “The hospital follows a process that allows staff, patients, and families to address the ethical issues or issues prone to conflict.”  The general argument seemed motivated by the assumption that ethics was in the air and that these norms have been well incorporated into the daily life of the hospital. This performance standard has been replaced with language asserting the critical importance of equity, a welcome endorsement that s applauded, but why does one need to be exchanged for the other, in the service of the good? An opinion is offered that removal of the clinical ethics element both impedes achieving the objective of equity and undercuts progress toward fostering clinical and organizational ethical practice within health care institutions. The article can be obtained at Where is Clinical Ethics in the Revised Hospital Accreditation Standards? - The Hastings Center.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Emergency Department Visits Related To Mental Health Disorders

A new report from the National Center for Health Statistics (NCHS) describes emergency department (ED) visits related to mental health disorders among adults and assesses differences in mental health-related ED visit characteristics by race and Hispanic ethnicity. Nationally representative estimates in this report are derived from data collected in the 2018–2020 National Hospital Ambulatory Medical Care Survey (NHAMCS). Rates of mental health-related ED visits by race and Hispanic ethnicity were highest among non-Hispanic Black adults (96.8 visits per 1,000 adults), followed by non-Hispanic White (53.4) and Hispanic (36.0) adults. Rates of ED visits for specific mental health disorders, including substance use disorders, anxiety disorders, and mood disorders, were also highest among non-Hispanic Black adults. A higher percentage of visits by Hispanic (57.7%) and non-Hispanic Black (49.5%) adults had Medicaid as the expected primary source of payment than visits by non-Hispanic White adults (36.1%).  

Skull Fractures In Female Versus Male Geriatric Patients Who Sustain Head Injuries

Head trauma is the leading cause of serious injury in the older adult population with skull fractures as a serious reported outcome. A study described in the March 2023 issue of The American Journal of Emergency Medicine that was conducted at two level-one trauma centers, serving a population of 360,000 geriatric residents aimed to evaluate the role of sex in the risk of skull fracture in patients over the age of 65. Among 5,402 patients enrolled, 3,010 (56%) were female and 2,392 (44%) were male. 4,612 (85%) of the head injuries sustained were due to falls, and 4,536 (90%) of all subjects were Caucasian. Overall, 199 patients (3.7%) sustained skull fractures. Males had a significantly greater rate of skull fracture when compared to females (4.6% vs 3.0%, OR 1.5, 95% CI: 1.2–2.1, p = 0.002). This trend also was seen across race/ethnicity and mechanism of injury. The outcome was unexpected, since previous literature indicated females being more susceptible to facial fracture.  

HEALTH TECHNOLOGY CORNER 

Inhalable Hydrogel Protects Lungs From SARS-Cov-2

Mutations in SARS-CoV-2, the virus that causes COVID-19, continue to produce new virus variants. Some mutations may confer resistance to the immunity induced by vaccines or prior SARS-CoV-2 infections. Thus, there is a need for strategies that could prevent infection by a range of SARS-CoV-2 variants. Physical barriers, such as the mucus lining of the airways, provide the first line of defense against infections. A research team at North Carolina State University set out to develop a way to reinforce this mucus barrier. They described their method, dubbed spherical hydrogel inhalation for enhanced lung defense, or SHIELD, in the journal Nature Materials on February 9, 2023. SHIELD consists of an inhalable powder of fine particles, less than 5 μm across, made from an absorbent polymer. The team tested whether it could protect against virus infection in mice. It was not toxic to cells in culture, and did not affect normal lung function in mice after two weeks of daily dosing.  

Technological Solutions To Loneliness—Are They Enough?

Loneliness is a major public health concern, particularly during pandemics such as COVID-19. It is extremely common and it poses a major risk to human health, such as higher rates of depression and increased mortality.Technological solutions including social media, robots, and virtual reality have been advocated and implemented to relieve loneliness. A paper in the March 2022 issue of the journal Bioethics explores the use of technological solutions from a normative perspective, asking whether and to what extent such measures should indeed be relied upon. A conclusion is that technological solutions are unquestionably part of the solution to loneliness, but that they cannot and should not constitute the whole solution because they arguably are insufficient to alleviate loneliness wholly and should not be perceived as sufficient. Another conclusion is that the essence of what it means to be human or the essence of human interactions cannot be substituted entirely by technological measures, sophisticated as they may be.

DEVELOPMENTS IN HIGHER EDUCATION

U.S. Senators Bernie Sanders (I-VT), chairperson of the Senate Health, Education, Labor, and Pensions (HELP) Committee, and Bill Cassidy (R-LA), ranking member of the Committee, on March 2, 2023 sent a letter to health care providers and other interested parties requesting information on the root causes of the current health care workforce shortage and potential ways to address it. The plan is to use what is derived from this invitational effort to identify bipartisan solutions that can be included in future legislation. Under new leadership in the 1st Session of the 118th Congress, the HELP Committee on February 16, 2023 conducted a hearing entitled, “Examining Health Care Workforce Shortages: Where Do We Go From Here?

Detailed workforce data can be derived for health professions, such as medicine, but that capability does not exist across the health professions. Although it is possible to generate information from professional organizations that collect membership data and political agencies that compile licensing data, uniformity often is lacking, which means that many gaps remain to be filled in constructing a comprehensive profile of health workforce shortages in the U.S.  Written responses to the letter from the two senators should be sent to HealthWorkforceComments@help.senate.gov by March 20, 2023. 

American College President Study

The American Council on Education’s (ACE’s) American College President Study (ACPS) has long served the higher education community as the most comprehensive, in-depth, and frequently cited source of information about the college presidency and pathways to higher education leadership. The last ACPS report was released in 2017. The recent survey of more than 1,000 presidents captures demographics; search and selection processes; career trajectories; and duties and responsibilities—with profiles of women presidents and presidents of color. New data this year will be revealed on the average age of aspiration, application, and appointment for college presidents by race, ethnicity, and gender, among other data points. Programming at the ACE annual meeting will include the unveiling of the report at a session called, “The American College President in 2023 and Beyond.”  

The Supreme Court And The Administration’s Student Debt Relief Plan

The fate of President Biden’s proposed student debt relief program is under review by the U.S. Supreme Court. An amicus brief signed by 128 House Republicans requests the Court to invalidate the program. Their argument is based on opposing an assertion of power to forgive every federal student loan in the country, potentially even a decade after the COVID-19 pandemic ends, which raises significant separation of powers concerns. House members contend that the power of the purse is one of Congress’s most potent checks against the executive branch, yet Petitioners’ overly broad reading of the HEROES Act risks encroaching on that power, as well as on Congress’s Article I legislative authority, by arrogating to the Secretary of Education the authority to forgive a trillion dollars in federal debt that otherwise would be owed to the Treasury. The brief states that the Court should require clear statutory authority before adopting an interpretation that risks significant conflict between the legislative and executive branches.  

Resources On Equal Athletic Opportunities Under Title IX

The Department of Education’s Office for Civil Rights on February 17, 2023 released three new resources to support equal opportunity in athletic programs consistent with Title IX of the Education Amendments of 1972. The documents are designed to help students, parents, coaches, athletic directors, and school officials evaluate whether a school is meeting its legal duty to provide equal athletic opportunity regardless of sex. The overview resource provides examples of the kinds of situations that could, depending upon facts and circumstances, raise Title IX concerns at any education level. The two specialized resources – one for K-12 schools and one for colleges and universities – offer information specific to these school communities. The resource for colleges and universities can be obtained here.

HEALTH REFORM DEVELOPMENTS

Since its enactment in 2010, the Affordable Care Act has undergone various refinements. A recent example stems from the passage of the Inflation Reduction Act (P.L. 117-169) that President Biden signed into law on August 16, 2022. One of its features is that Medicare will be able to negotiate drug prices starting in 2026. Nearly 20 years after the creation of the Medicare Part D program, the Centers for Medicare & Medicaid Services (CMS) will be able to negotiate drug prices directly with manufacturers. Thus far, the Congressional Budget Office (CBO) has estimated the total savings achieved each year for negotiation, but has not publicly identified the drugs anticipated to be negotiated. The March 2023 issue of the Journal of Managed Care+Specialty Pharmacy (JMCP) contains an article regarding drugs that are likely subject to Medicare negotiation.  

Medicare will be able to negotiate drug prices starting in 2026. By 2028, prices for 38 drugs dispensed in pharmacies and two drugs provided in physician offices will be negotiated. Medicare drug price negotiation will benefit patients with common diseases, such as diabetes, cancer, respiratory conditions, or cardiovascular disease. Combined, the 40 products eligible for negotiation in 2026-2028 accounted for $67.4 billion in gross Medicare spending in 2020. Part D drugs eligible for negotiation in 2026-2028 include seven inhalers, eight antidiabetics, five kinase inhibitors, and three oral anticoagulants. In all but five cases, high-spend drugs ineligible for negotiation were disqualified because of generic or biosimilar competition. By generating the list of drugs likely subject to Medicare negotiation in the initial years, the Journal article authors hope to provide researchers, policymakers, prescribers, and patient advocates with expectations on which drugs are expected to see reductions in beneficiary cost sharing. 

Consumer Adoption Of Digital Health

Based on a new survey released by Rock Health, a non-profit venture fund, and Stanford University’s Center for Digital Health, most U.S. adults prefer obtaining prescription refills and care for minor illnesses via telemedicine rather than in-person care. Since 2015, Rock Health annually has surveyed a U.S. Census-matched sample of adults to check the pulse on consumers’ attitudes toward and behaviors surrounding digital health. Respondents used their personal desktop, laptop, smartphone, or tablet to complete the survey in English. The 2022 study of more than 8,000 adults found that approximately two-thirds of Americans prefer in-person care for visits related to chronic conditions and mental health, while three-quarters of adults prefer in-person visits for annual wellness checks, emergency care, and physical therapy. 

In the 2022 Survey, 80% of all respondents reported having accessed care via telemedicine at some point in their lives, an increase of eight percentage points from 2021. While telemedicine use continues to vary across demographic segments, 2022 saw notable adoption increases among groups that have long been underserved in health care. The greatest year-over-year increases were observed among respondents aged 55+ (76%, up from 64%), respondents living in rural areas (73%, up from 60%), and respondents without health insurance at the time of the survey (50%, up from 37%). Telemedicine use also increased among women, with 82% of respondents reporting having used telemedicine (a 9% increase from 2021). Eighty-two percent of Hispanic respondents reported telemedicine use, reflecting a 9% increase since 2021, the greatest percentage point increase among all racial and ethnic groups captured by the Survey.

Protecting Beneficiaries From “Junk” Health Plan Coverage

A group of Senate Democrats sent a letter to Department of Health and Human Services Secretary  Xavier Becerra on February 22, 2022 urging the administration to take immediate action to address the availability of short-term, limited duration health insurance plans that violate the Affordable Care Act. The letter expresses concerns about individuals who will lose Medicaid coverage gained during the COVID-19 pandemic as state programs begin their redetermination processes. Beginning in April 2023, millions of Americans are at risk of losing Medicaid coverage that they have relied upon during the COVID-19 pandemic. Without additional protections they could find themselves enrolled in “junk” plans that do not provide comprehensive coverage or protection for individuals with pre-existing conditions. Steps also must be taken to ensure that these plans are not allowed to proliferate further.

AVOIDING THE THIRD RAIL

An old adage in the nation’s capital that many legislators have abided by is to avoid issues that are considered to be as perilous as being exposed to a subway third rail. The basic idea is that if you touch it, you will perish. Two prominent third rail items are the Social Security and Medicare programs. A vivid illustration occurred on Capitol Hill on February 7, 2023 during President Biden’s state of the union address when he suggested that Republicans may be inclined to damage those two programs, such as by reducing benefits or raising taxes.  

As stated at the opening of the Olympics every two and four years, “Let the games begin.” Democrats initiated their concerns by pointing to a proposal by Senator Rick Scott (R-FL) to sunset all federal programs every five years. If not renewed by fresh legislation then, they would be allowed to expire. Subsequently, he revised his plan by indicating that Social Security, Medicare, national security, veterans benefits, and other essential services would be specific exceptions.  

Whenever Democrats and Republicans are under assault, they have a gift for rapidly turning matters around so that any former accuser now becomes the accused. After vigorously denying that they would ever adopt behavior causing distress among Social Security and Medicare beneficiaries, Republicans retaliated by pointing to new rules from the Centers for Medicare and Medicaid Services (CMS) in the Biden administration aimed at reducing overpayments to Medicare Advantage plans. Approximately 40% of all beneficiaries are enrolled in Advantage plans that serve as an alternative to traditional Medicare by being administered by private health insurers. These plans now must pay back the government for overpayments as shown by a recently finalized rule that would over 10 years recoup more than $4 billion in overpayments to plans. Also, by offering to increase CMS support of Medicare Advantage by only 1% next year, the figure is looked upon as a benefit cut because it fails to keep pace with inflation.   

A steady growth in the number and proportion of individuals in the U.S. reaching age 65 every year guarantees that Congress must continue to devote attention to preserving the solvency of both the Social Security and Medicare programs. A related issue is the Medicaid program, which is funded by federal and state governments. It faces many of the same problems as Medicare, such as a growing number of older beneficiaries, many of whom must deal with multiple crippling health and health-related social problems involving long-term care. The COVID-19 public health emergency, which has been in effect since January 2020, is scheduled to end on May 11 of this year. A result is that states have had to begin a process of reassessing eligibility for their Medicaid-covered residents. Under the Families First Coronavirus Relief Act (FFCRA), states received enhanced federal funding in exchange for covering all enrolled Medicaid beneficiaries continuously. This requirement ends on April 1, after which states can begin disenrolling individuals who are determined to be eligible for Medicaid no longer.

ChatGPT AND A LITTLE TINK

Albert Einstein achieved fame for his development of theories of special and general relativity. He wrestled over the decades, however, with the task of producing a unified field theory that linked electricity, magnetism, gravity, and quantum mechanics. Whenever feeling stumped by obstacles in successfully completing that pursuit, he would state “I will a little tink.” English was not his native language.  

November 2022 marked the release of a new open source, natural language processing tool by OpenAI called ChatGPT. This new chatbot is designed to simulate human conversation in response to prompts or questions (GPT stands for “generative pretrained transformer”). In January 2023, Nature reported on two preprints and a pair of articles published in the science and health fields that included ChatGPT as a bylined author. These articles and their nonhuman “authors” already have been indexed in PubMed and Google Scholar.  

Two articles published in the March 2023 issue of the journal Lancet Digital Health discuss both the substantial ethical implications of this latest technology innovation as well as how it has potential to improve health care delivery. The publishing industry, for example, is at risk of undesirable consequences because when presented with a query, ChatGPT automatically will generate a response based on thousands of internet sources that may not involve any further interventions by the user. Scholarly manuscripts can be generated that also are accompanied by appropriate references. Ethical considerations abound concerning copyright, attribution, plagiarism, and authorship when AI produces academic text. These concerns especially are pertinent because when copy is AI generated, it currently is imperceptible to human readers and anti-plagiarism software. A significant concern is that the functionality of ChatGPT also has the capacity to cause harm by producing misleading or inaccurate content. 

Presently, ChatGPT is available to use without cost, but OpenAI's leadership has affirmed that free use is temporary and the product eventually will be monetized.  One commercial option for the platform could involve a form of paywall, which might entrench existing international inequalities in scholarly publishing. Although institutions in socioeconomically advantaged areas could probably afford access, those in low- and middle-income countries might not be able to do so, thereby widening existing disparities in knowledge dissemination and scholarly publishing.  

Apart from worrisome aspects of this new innovation, the delivery of health care services may benefit from expanded capabilities associated with further development of ChatGPT. One potential application could be to generate discharge summaries, which may be left under-prioritized that result in delays in patients’ discharges from clinical facilities or insufficient discharge summaries. All things considered, from a much wider perspective it would be advantageous to devote a little more “tink” to contemplating how to optimize the potential contributions this exciting technology has to offer its users.

CLIMATE CHANGE, INSECTS, AND HUMAN HEALTH

The science of astronomy for many centuries was influenced by a Ptolemaic formulation that placed the earth at the center of the universe, with other celestial bodies revolving around that planet. This conception subsequently was replaced by a Copernican model that viewed the sun as being at the center of the universe, with other bodies such as the earth revolving around it. In a parallel sense, it is possible to entertain a view that considers humans as being at the vital center of the animal kingdom, with all other creatures playing a more secondary role. The term anthropogenic has been coined to indicate the dominance of our species. The Oxford English Dictionary (OED) defines it as of or relating to (the study of) human origins or human development (in various contexts). It can be used as an adjective as shown by the expression “anthropogenic climate change.” As discussed in the February 2023 issue of the journal Ecological Monographs, climate warming is considered to be among the most serious of anthropogenic stresses to the environment, because it not only has direct effects on biodiversity, but it also exacerbates the harmful effects of other human-mediated threats.  

Among the most affected groups of animals are insects, central components of many ecosystems, for which climate change has pervasive effects from individuals to communities. The authors issue a warning that if no action is taken to better understand and reduce the action of climate change on insects, an ability to build a sustainable future based on healthy, functional ecosystems will be reduced drastically. A growing body of empirical literature shows that many populations of insects are declining rapidly across many parts of the biosphere. Observed trends in the demographics of many taxa, including important functional groups like pollinators, nutrient cyclers, and natural enemies, as well as in the abundance of crop, forest, and urban pests, currently is considered serious enough to merit profound concern. Important ecosystem services provided by insects are pollination, pest control, and nutrient recycling. Insects and their products also provide resources for higher trophic level organisms, including humans. In natural (unmanaged) ecosystems, abundances of pathogen and vector species are controlled through various food web interactions and habitat conditions, whereas anthropogenic land use changes, such as deforestation, habitat fragmentation, and agricultural development can modify these interactions with consequences for disease transmission affecting humans. The paper summarizes means of safeguarding insect populations for posterity and urges that initiatives be taken to implement them.

URBAN-RURAL DISPARITIES IN DEATHS OF DESPAIR

Although improvements in socioeconomic conditions and medical and technologic advancements contribute to reduced mortality rates over the past century, health disparities across various dimensions (e.g., race/ethnicity, gender, geographic location, and age) are becoming larger than ever in the U.S. As discussed in a paper in the February 2023 issue of the American Journal of Preventive Medicine, recent studies indicate increasing geographic inequalities in life expectancy. Regional variation in health outcomes is explained by differences in community-level factors, such as residential location, access to health care, access to healthy food, and proportion of college graduates. Health disparities can arise or be exacerbated when there is unequal access to these opportunities or resources. A dramatic increase in mortality occurs because of drug overdoses, suicide, and alcohol poisoning, referred to as deaths of despair or stress-related conditions (SRCs). A rise in SRC (2000-2015) first was reported among the non-Hispanic (NH) middle-aged White population in rural areas across the U.S.  

Midlife death rates also rose significantly between 1999 and 2016 among people of color that was driven primarily by drug, alcohol, and suicide deaths, but also because of increases in dozens of organ ailments, such as hypertensive heart disease and liver cancer. In general, rural areas are likely to have fewer socioeconomic resources than urban areas because of their physical location and lack of material and human resources. Separation from others who may provide social support also could exacerbate mental health problems and thus increase the risk of drug, alcohol, and suicide mortality. A study described in the aforementioned paper indicates that SRC mortality rates from 2004 to 2016 were not distributed randomly across the contiguous counties in the U.S. Findings suggest that educational attainment, disability status, access to health care, and contextual conditions can serve as measures to develop more effective prevention and intervention programs to target specific localities and tackle the deaths of despair epidemic. 

OBTAINABLE RESOURCES (Copy)

Levels & Trends In Child Mortality 

Child survival is a critical marker of a thriving society. In 2021, there were an estimated five million deaths of children under age five. Sadly, this devastating loss of life was mostly preventable with widespread and effective interventions like improved care around the time of birth, vaccination, nutritional supplementation and water and sanitation programs. Without urgent action to reduce under-five mortality, more than 50 countries will not meet the underfive mortality target by 2030 and more than 60 countries will miss the neonatal mortality target. A new report by representatives from UNICEF, the World Health Organization, the World Bank, and the U.N. Department of Economic and Social Affairs indicates countries can take steps to further child mortality further, such as: Increase investment in primary health care; Scale up prevention and treatment of the leading causes of child mortality, such as newborn complications, pneumonia, diarrhea, malaria, and noncommunicable diseases; Provide sufficient food; Ensure water, sanitation, and hygiene in health facilities; and Establish peace and security. The report can be obtained here.

Race, Ethnicity, And The Design Of State Grant Aid Programs 

Most states use grant programs to lower the prices individual college students pay for their education. Unlike overall reductions in tuition prices for public institutions, these grant policies allow some students to pay less than others. The programs’ policy design and eligibility requirements vary by state and even across sectors. Some state grant aid, based on factors other than financial need, is distributed to students based on high school grades or test scores, intended courses of study, parental occupation, or other characteristics. According to a new report from the Urban Institute, this aid usually aims to reward achievement, to induce talented students to stay in state for college, to encourage students to prepare for occupations in high demand, or to acknowledge the challenges students in specific circumstances face. Need-based aid programs direct funds toward students for whom paying for college is difficult because of financial circumstances. These policies are rooted in both equity and efficiency goals. There is broad consensus that it is unfair to deny college access to potential students because of their inability to pay. Providing sufficient financial support to enable all admitted students to enroll in and succeed at an institution increases labor force productivity and reduces the need for publicly funded social supports. The report can be obtained here.

The Demographic Outlook: 2023 To 2053 

The size of the U.S. population, as well as its age and sex composition, affects the economy and the federal budget. For example, the size of the population ages 25 to 54 affects the number of individuals employed. Likewise, the size of the population age 65 or older affects the number of beneficiaries of federal programs, such as Social Security and Medicare. The Congressional Budget Office (CBO) in a new report describes its population projections, which underlie the agency’s baseline budget projections and economic forecast that will be published later this year. According to CBO projections, the Social Security area population, the relevant population for calculating Social Security payroll taxes and benefits and the measure of population used in this report, increases from 336 million individuals in 2023 to 373 million in 2053. As growth of the population age 65 or older outpaces growth of younger age groups, the population is projected to continue to become older and larger (by 0.8% in 2052, the final year of the projections that CBO released last year) and to grow slightly faster, on average, in this year’s projections, for two main reasons. First, net immigration is projected to be higher and second, mortality rates for the group age 65 or older are projected to be lower over the first two decades of the projection period. The decline stems from fewer deaths in 2022 due to COVID-19 infections than CBO previously projected. The report can be obtained here.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Reasons For Receiving Or Not Receiving Bivalent COVID-19 Booster Vaccinations

Bivalent COVID-19 booster vaccines, developed to protect against both ancestral and Omicron BA.4/BA.5 variants, are recommended to increase protection against SARS-CoV-2 infection and severe disease. Relatively few eligible U.S. adults have received a bivalent booster dose, however, and reasons for low coverage are unclear. As indicated in the January 20, 2023 Morbidity and Mortality Weekly Report, an opt-in Internet survey of 1,200 COVID-19–vaccinated U.S. adults was conducted to assess reasons for receiving or not receiving a bivalent booster dose. The most common reasons cited for not receiving the bivalent booster dose were lack of awareness of eligibility for vaccination (23.2%) or of vaccine availability (19.3%), and perceived immunity against infection (18.9%). Participants who still had not received the booster dose most commonly reported being too busy to be vaccinated (35.6%). To help increase bivalent coverage, officials should use evidence-based strategies to convey information.  

Mortality In The United States, 2021

A new Data Brief (No. 456--December 2022) from the National Center for Health Statistics (NCHS) presents final 2021 U.S. mortality data on deaths and death rates by demographic and medical characteristics. Among the findings are the following: Life expectancy for the U.S. population in 2021 was 76.4 years, a decrease of 0.6 year from 2020. The age-adjusted death rate increased by 5.3% from 835.4 deaths per 100,000 standard population in 2020 to 879.7 in 2021. Age-specific death rates increased from 2020 to 2021 for each age group one year and older. Nine of the 10 leading causes of death in 2021 remained the same as in 2020. Heart disease, cancer, and COVID-19 remained the top three leading causes. The infant mortality rate was 543.6 infant deaths per 100,000 live births in 2021. The change in infant mortality from 2020 was not statistically significant. 

HEALTH TECHNOLOGY CORNER 

Passive Monitoring By Smart Toilets For Precision Health 

Precision health is an approach to prevent, diagnose, and monitor disease using data gleaned from an individual’s biological information. Passive monitoring in a smart home setting, where appliances and devices are connected and controlled automatically, may provide such information. As described in the February 1, 2023 issue of Science Translational Medicine, of the possible locations in a smart home, the bathroom, and more specifically the toilet, is particularly well suited for such passive sensors. A “smart toilet” not only can monitor standard health characteristics, including temperature, heart rate, and oxygenation through sensors in the toilet seat, but also can collect biological samples (i.e., urine and stool) that contain useful health information. Yet, a reluctance to discuss excreta openly hampers the development and acceptance of smart toilets, which hold the potential to integrate urine and stool analyses seamlessly as part of routine toileting events and to serve as a gateway to the “digitalization” of health care in the home. 

Use Of Peptide 3D-Printing Inks To Advance Regenerative Medicine

Is it possible to build complex structures for housing cells using a material as soft as Jello? Scientists at Rice University believe that 3D printing represents a primary fabrication strategy used in biomedical research as recent efforts have focused on the 3D printing of hydrogels to create structures that better replicate the mechanical properties of biological tissues. As described in a study published on January 4, 2023 in the journal Advance Materials, these investigators envision that eventually the goal is to print structures with cells and grow mature tissue in a petri dish. These tissues then can be transplanted to treat injuries, or used to learn about how an illness works and to test drug candidates. There have been other attempts to 3D-print using other self-assembling peptides, but this effort is the first time that any self-assembling peptide system has been used to 3D-print such complex structures successfully. The structures were printed with either positively charged or negatively charged multidomain peptides.  

CONGRESSIONAL LEGISLATIVE OUTLOOK

Using multiple poll results, an article published in the February 2, 2023 issue of the New England Journal of Medicine seeks to explain how the outcome of the 2022 mid-term election is likely to affect health policy issues. Data are derived from three types of polls: (1) a 2022 national exit poll, comprising the responses of voters as they exited voting places and those from telephone and online interviews with those who had voted before election day; (2) a national poll of voters conducted by Harvard T.H. Chan School of Public Health at the time of the election, including responses from telephone and online interviews with those who had already voted and likely voters during the week leading to election day; and (3) nine other polls conducted by telephone, online, or both with samples of U.S. adults between September 2020 and October 2022, with one exception.  

A general conclusion is that after the 2022 election, critical health policy issues will face a sharply divided Congress, which is likely to hinder their resolution. Reflecting attitudes of their own parties’ voters, Republican and Democratic members in Congress will differ not only in their support for specific policies, but also in underlying values, e.g., in a December 2020 poll of the general public, 87% of Democrats said it is the responsibility of the federal government to make sure all Americans have health care coverage, as compared with only 22% of Republicans. It can be expected that Republicans are likely to oppose any major expansion in domestic spending, including for health-related issues. A majority of Republicans believe the major domestic spending bills proposed by the Biden administration have been inflationary, while a majority of Democrats do not. In a March 2022 poll of the public, 87% of Democrats had a favorable view of the Affordable Care Act (ACA) as compared with 21% of Republicans. Thus, enacting any extensive ACA enlargement is unlikely. Reducing health care costs and drug prices are a top issue, but whether any agreements can be reached is unclear.  

Periodically, some high drama unfolds when there is a necessity to raise the national debt ceiling. For example, when President Barack Obama was in office in 2011, an impasse was not resolved until a couple of days before the ceiling was about to be reached. Whenever that situation occurs, financial markets can become quite agitated as the nation appears unable to continue meeting its financial obligations. Yet, the ceiling was raised with less effort three times when Donald Trump was president, a period in which Republicans were willing to cooperate even though the amount of debt increased by eight trillion dollars.  

Currently, however, members of that party are much less inclined to support an increase unless it is accompanied by concrete steps to reduce federal spending. Whether popular entitlement programs, such as Medicare and Social Security might be targets is worrisome. Steady growth in the portion of the population age 65 and older, combined with the fact that many of these individuals have two or more chronic health problems, essentially means that such expenditures will continue to increase.

ACHIEVING MAJOR HEALTH POLICY GOALS

Health policy in the United States centers on providing access to all of the nation’s inhabitants in need of health care, controlling costs, and assuring the provision of high quality services. Related to the notion of quality is the necessity of having suitable quantitative measures to evaluate the health of the population. As indicated in an article published in January 2023 in the Journal of Health Economics, mortality indicators (such as life expectancy) typically were used first. Although still of great importance, a growing consensus exists to combine them with morbidity indicators. Presently, it is widely accepted that the benefit a patient derives from a particular health care intervention can be defined according to two natural dimensions: quality of life and quantity of life.  

Quality-adjusted life years (QALYs) were developed to combine the two natural dimensions. Arguably it is the most widely accepted methodology in the economic evaluation of health care, serving as a reference standard in cost-effectiveness analysis. Alternative health outcome measures also became popular, such as Disability-adjusted life years (DALYs). Primarily a measure of disease burden, it arose in the early 1990s as a result of an effort to quantify the global burden of premature death, disease, and injury and to make recommendations that would improve health, particularly in developing nations.  

An illustration of how various measures are employed operationally is provided by the Inflation Reduction Act (P.L. 117-169) enacted in August 2022. This new law empowers the Centers for Medicare and Medicaid Services (CMS) to negotiate directly with pharmaceutical companies to set prices for a limited set of high-cost drugs covered by Medicare. The law does not, however, detail a process for determining fair prices, other than a consideration for how long drugs are on the market. A report published on October 27, 2022 by The Commonwealth Fund discusses how historically, prices for drugs in the U.S. have been disconnected from the clinical benefit they provide. Without this information, health insurers and pharmacy benefit managers have no way of knowing which investments are the most beneficial. Several approaches are described to assess a drug’s value, each with its advantages and drawbacks. Along with QALYs and DALYs, they include: Life year (LY), Equal value life years (evLY), Health years in total (HYT), Value of a statistical life (VSL), Added benefit, Clinical effectiveness rating, Multicriteria decision analysis (MCDA), and Social return on investment (SROI). 

Some controversy exists in this aspect of health policy as shown by the introduction on January 24, 2023 of the Protecting Health Care for All Patients Act (H.R. 485) in Congress. The bill would prohibit the use of QALYs in all federal programs, an expansion from the current prohibition that only applies in a limited fashion to the Medicare program. A rationale is that this discriminatory metric intentionally devalues treatments for disabled individuals and patients with chronic illnesses for purposes of determining whether the treatment is cost-effective enough to be paid for by the federal government.

UNSETTLED SCIENCE AND TERMINOLOGY INEXACTITUDES

The perspective that a body of knowledge is settled or broadly considered to be proven, is not exclusive to a particular science, but occurs widely. As described in the January 2023 issue of the journal Medical Care, health services research is not immune to this phenomenon. Thomas Kuhn warned in The Structure of Scientific Revolution, that in what he referred to as normal science, it is the current paradigms that hold substantial sway over scientific disciplines. These paradigms provide the structure by which scientists go about finding out new knowledge to fill in the accepted framework of understanding. Evidence consistent with the paradigm is accepted as verification that the theory or paradigm is correct while anything contrary is questioned as to its authenticity. Thus, current paradigms of normal science may persist in the face of accumulating anomalies until it is not possible to dismiss or otherwise explain them away.  

A paper in the December 2022 issue of the journal Neurology indicates that disease terminology should convey an accurate and understandable picture, ideally with corresponding prognostic, therapeutic, and pathophysiologic utility. Optic neuritis refers to an inflammatory optic nerve process related to multiple sclerosis or other identifiable autoimmune diseases of the CNS. Recently, salient clinical features distinguishing optic neuritis have been identified, highlighting the need for diagnostic precision superseding crude binary classifications of "typical" vs "atypical" optic neuritis. The authors propose elimination of the term "atypical optic neuritis" since the "itis" modifier is often erroneous and the term may instill a false sense of diagnostic security in the clinician, implying a more definitive diagnosis and resulting in therapeutic delays or administration of therapies with deleterious effects. Considered more broadly, current inconsistencies in terminology act as barriers to research and development of the good practices required for effective provision of rehabilitation and assistive technology (AT). According to Issue 8 in 2022 of the journal Disability and Rehabilitation: Assistive Technology, information exchange among all participants in the AT value chain can only become interoperable when terminology standards for concepts, terms, and definitions are established and used. The development of more precise terminology in health care should be instrumental in producing more settled rather less settled science.

DEBATE OVER ADOPTION OF PERMANENT STANDARD TIME IN THE U.S.

A national debate in the United States over Daylight saving time (DST) is a timely issue. In March 2022, the U.S. Senate passed the Sunshine Protection Act to make DST permanent in states that previously have chosen to make that change. The U.S. House has not passed this legislation. Daylight saving time (DST) refers to the practice of advancing clock time by one hour each spring, with a return (setting back) to standard time (ST) each fall. Numerous sleep and circadian societies have published statements in support of permanent ST, which also has received support from multiple medical societies and organizations. Recently, the Sleep Research Society (SRS) in the December 2022 issue of its journal Sleep advocates the adoption of permanent ST. In contrast, on the opposing side of the debate is that the business community, including the National Association of Convenience Stores and the Sporting Goods Manufacturing Association support permanent DST. One of the most prominent arguments in the debate over adopting permanent ST (rather than permanent DST) is how health, sleep, and circadian biology are affected.  

DST shifts daylight into the early evening in exchange for less daylight in the early morning when more individuals are presumed to be asleep. This light exchange has both social and economic benefits, with more natural light for evening activities and less need for artificial light in the evening. Nonetheless, there are health consequences to DST for those whose school or jobs require them to awaken early. Evening light extended too close to bedtime also can disrupt sleep patterns. Compared to individuals living on the eastern edge of a time zone, residents living on the western edge of a time zone, who obtain light later in the morning, and later in the evening, self-report having less sleep based on time-use data. Sleep loss in adults has been associated with weight gain and obesity; diabetes; hypertension; heart disease; and stroke, depression, and increased risk of death, along with impaired immune function, increased pain, impaired performance, increased errors, and greater risk of accidents. Sleep loss in children has been associated with attention, behavior, and learning problems; along with increased risk of accidents, injuries, hypertension, obesity, diabetes, depression, self-harm, suicidal thoughts, and suicide attempts.