HEALTH REFORM DEVELOPMENTS

According to some encouraging news on May 24, 2023 from the Congressional Budget Office (CBO), enrollment in both Medicaid and marketplace plans have reached historic highs in 2023, mostly because of temporary policies (developed during the pandemic) that kept beneficiaries enrolled in Medicaid and that enhanced the subsidies for health insurance purchased through marketplaces. The share of the population under age 65 that is uninsured is at an unprecedented low of 8.3%. Medicaid enrollment grew from 60.5 million in 2019 to 76.6 million in 2022. In 2023, Medicaid covers 28.1% of the under-65 population and subsidized marketplace plans cover 5.2%. Employment-based insurance covers more than half (57.3%) of that population.  Low-income individuals have seen the largest gains in coverage and the largest declines in the share who lack insurance.  

Offsetting the positive news is that during the next year and a half, CBO expects substantial declines in enrollment in Medicaid as the continuous eligibility provisions implemented during the pandemic unwind. CBO projects that 6.2 million of the beneficiaries leaving Medicaid will become uninsured. Also, if the enhanced subsidies expire after 2025, as scheduled, 4.9 million fewer individuals are estimated to enroll in marketplace coverage, instead enrolling in unsubsidized nongroup or employment-based coverage or becoming uninsured. By 2033, the share of the population who is uninsured is projected to be 10.1%.  

Non-Compete Agreements, Job Mobility, And Wages

Noncompete agreements (NCAs) can restrict workers from seeking employment with a competitor or from starting a competing business. While helping companies protect confidential information, they also have the potential to lead to less job mobility and lower wages for workers. Employers historically have used these agreements for highly skilled workers and executives with access to trade secrets or other proprietary information. As discussed in a report made available on May 11, 2023 from the Government Accountability Office (GAO), a congressional watchdog agency, employers who were surveyed had all types of workers sign them, from executives to hourly employees, even though many lower wage workers may not have access to confidential information. Meanwhile, identical bills introduced in the Senate (S. 220) and the House (H.R. 731), the Workforce Mobility Act of 2023, would prohibit the use of such agreements except under certain circumstances.  

Two occupation-specific studies that examined health care workers found that substantial proportions of certain personnel are subject to NCAs. Primary care physicians in group practices are an example of individuals who had an NCA. Many workers do not have access to employers’ more sensitive information, which often makes this reason for having NCAs irrelevant. Lower-wage workers are unlikely to have access to trade secrets and some health care workers subject to NCAs, such as nurses and nursing assistants, would not have access to proprietary information that would give another hospital a competitive advantage. Also, 78% percent of responding employers with NCAs in the health care and social assistance industry (25 of 32) reported having NCAs to prevent recruitment of their staff, investors, or other resources, compared to smaller proportions of the other most common industries among the responding employers, e.g., 54% of manufacturers (26 of 48).  

Sharing Health Information

Epic, a health care software company based in Verona, Wisconsin, favors the goal of exchanging data across the entire health ecosystem. Now that some hospital systems are making a commitment to join the nationwide framework known as the Trusted Exchange Framework and Common Agreement (TEFCA) to share patient health data electronically, Epic announced in late May 2023 its first group of hospitals to take the step. More than 30 hospital systems have indicated they will join, including Kaiser Permanente, Johns Hopkins Medicine, and the Mayo Clinic. TEFCA is a public-private partnership that sets expectations and guidelines for sharing health information. More than half of hospitals are aware of TEFCA and plan to participate. Better sharing of patient records has the prospect of improving health care and avoiding clinical errors. Another item in this June 2023 issue of the newsletter TRENDS is about structural ableism. Electronic health records play an important role in the lives of individuals with a disability. One reason is that it becomes possible to identify patients who require necessary accommodations. Secondly, the electronic health record makes it possible to track the quality of care being provided. 

FEDERAL DEBT CEILING ELATION AND SORROW

A major focal point during recent weeks in the nation’s capital has been to avoid an impending crisis expected to occur unless constructive action is taken to prevent the federal debt ceiling limit from being reached in early June. The current borrowing limit is $31.4 trillion. President Biden and his Democrat colleagues in Congress for several months advocated that a clean bill should be developed, which entails no restrictions on current federal government expenditures. That view clashed with the perspective of Republicans in both legislative chambers who share a core belief that it is necessary to rein in spending that regularly contributes to unsustainable growth in the overall federal deficit. Achieving a final result following rounds of strenuous negotiations is perceived as producing either elation or sorrow, depending on where each policymaker stands along the political divide of liberal v. conservative.   

Passage of the Fiscal Responsibility Act of 2023 (H.R. 3746) made it possible to suspend the debt ceiling until the first quarter of 2025. The bill was passed in the House of Representatives on a vote of 314-117, which included 165 Democrats. The Senate gave its approval the following day on a vote of 63-36. President Biden signed the legislation into law (P.L. 118-5) on June 3. Otherwise, only two days later, the government would have been compelled to reneg on its debt obligations in the absence of a borrowing cap extension. Some features of the bill are as follows: 

The Congressional Budget Office (CBO) estimates that the deficit could be reduced by $1.5 trillion through fiscal year (FY) 2033, including a $1.3 trillion reduction in discretionary spending that starts in FY 2024.  

A 1% sequester on discretionary spending will be triggered if Congress fails to pass all FY 2024 appropriations bills. That fiscal year begins on October 1, 2023. 

Military spending would increase about 3% in FY 2024.  

Other provisions will reduce some funding for the Internal Revenue Service, tighten some work requirements for the Supplemental Nutrition Assistance Program (SNAP), and attempt to speed permitting for energy projects.   

Student-loan payments have been suspended since 2020 because of the COVID-19 pandemic. Interest accrual and repayments would restart by the end of August 2023.  

Major programs, such as Medicare and Social Security are left untouched by spending cuts in P.L. 118-5.

SEMIOTIC AND LINGUISTIC INFLUENCE

Semiotics has a focus on the study of signs and symbols. Failure to interpret them correctly in interactions between patients and clinicians may lead to unfortunate consequences that compromise health care quality. For example, touching a patient may be considered a sign of caring whereas a failure to touch may be perceived by a patient as a radically different kind of unwelcome symbol.  

The study of linguistics indicates that a single word may have several referents. According to the June 2023 issue of the Journal of Applied Gerontology, the term ageism initially was coined in 1969. Since then, it has gone through numerous transformations, reflecting different nuances. Similarly, other “ism” words are used currently to characterize the interaction between patients and clinicians, such as racism, sexism, and ableism. It also is possible to be affected by more than one ism. Ironically, someone who is both an ageist and an ableist eventually will enter old age cohorts and be affected by one or more disabilities. 

Until recent years, it was common to refer to an individual as being disabled or handicapped. The emphasis presently is on the employment of person-centered language (PCL) in health care. For example, it is preferable to refer to a patient with cancer instead of using the expression a cancer patient. The June 2023 issue of the journal Obesity discusses a study in which of the 991 articles examined, only 24.02% of publications adhered to PCL. Non-PCL in reference to obesity is widely evident, however, in weight-focused periodicals despite recommendations for adherence to PCL guidelines. It is believed that continued use of non-PCL in reference to obesity in research inadvertently may perpetuate weight-based stigma and health disparities in future generations. 

Racism also may occur alone or with ableism. The June 2023 issue of the American Journal of Psychiatry refers to an investigation in which Black and Hispanic veterans were more likely than White veterans to have an alcohol use disorder (AUD) diagnosis despite similar levels of alcohol consumption. Ableism would be applicable had they been classified as alcoholics rather than as individuals with an AUD. The difference was greatest between Black and White men. At all but the lowest and highest levels of alcohol consumption, Black men had 23%–109% greater odds of an AUD diagnosis. The findings were unchanged after adjustment for alcohol usage, alcohol-related disorders, and other potential confounders.  

Moreover, schools in the health professions may constitute a highly competitive environment where the most accomplished students are able to obtain the most prestigious and best selective post-graduation placements for internships, residency positions, and employment. Students with a disability may be reluctant to disclose that they have a particular condition, especially one that is invisible such as social anxiety disorder, fearing that doing so may hurt their future prospects, an outcome of structural ableism. The same holds true in workplace settings where seeking any special accommodation, such as needing more time to complete assignments, has the potential of triggering stigmatization by co-workers and employers.

EXPERIMENTAL CRISPR THERAPY TREATMENT

More than 50 experimental studies are underway that use gene editing in human volunteers to treat everything from cancer to HIV and blood diseases. Most of these investigations, about 40 of them, involve CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats), the most versatile of the gene-editing methods, which was developed only 10 years ago. CRISPR is a revelation to scientists because of how it can snip the genome at specific locations. A cutting protein is paired with a short gene sequence that acts like GPS, zipping to a predetermined spot in an individual's chromosomes. According to an article in the May/June 2023 issue of the journal MIT Technology Review, one of the first patients treated using a CRISPR procedure, in 2019, was Victoria Gray. At the Third International Summit on Human Genome Editing, held in London in March 2023, she described to the audience how her earlier battle with sickle-cell disease resulted in episodes that left her hospitalized for months at a time.  

Then she underwent a treatment that involved editing the genes in cells from her bone marrow. Within minutes of receiving a transfusion of edited cells, she shed tears of joy. The company developing her treatment, Vertex Pharmaceuticals, has treated more than 75 patients in its studies of sickle-cell and a related disease, beta thalassemia. The therapy could be approved for sale in the U.S. within a year. It is widely expected to be the first treatment using CRISPR to go on sale, but a price has not been announced. Other biotech companies, such as Intellia, Beam Therapeutics, and Editas Medicine, are hoping they can use this technology to develop successful treatments. Many are running trials. A challenge facing all these efforts remains placing CRISPR where it needs to go in the body, which is not easy to accomplish. In Gray's case, doctors removed bone marrow cells and edited them in the laboratory. Before they were added back to her body, however, she underwent punishing chemotherapy to kill off her remaining bone marrow in order to make room for the new cells. Meanwhile, thousands of other inherited diseases that could be treated with CRISPR are being ignored because most of them are too rare to be a viable commercial opportunity.

DATA SHARING AND COMMUNITY RESEARCH PARTNERSHIPS

During the past 20 years, the National Institutes of Health (NIH) has implemented policies designed to improve the sharing of research data. The first requirements were established in 2003. Since then other mandated policies to promote access to research data and resulting findings have been adopted, including in 2022: the NIH public access policy for publications, NIH genomic data sharing policy, and National Cancer Institute Cancer Moonshot public access and data sharing policy. In January 2023, a new NIH data sharing policy went into effect, requiring researchers to submit a Data Management and Sharing Plan in proposals for NIH. It requires consideration of: (1) how data management and sharing are addressed in the informed consent process; (2) limitations on subsequent use of data; and (3) whether access to de-identified data should be controlled. Data sharing policies are predicated on the idea that sharing information is an important component of the scientific method. It enables the creation of larger data repositories to support innovative research questions that may not be possible in individual studies.  

Data sharing allows valuable information to be used for new hypotheses that may extend beyond original plans for the data. It also has been argued that data sharing represents an ethical obligation by possibly maximizing the learning that comes from federal investment in research and from the contributions of volunteer research participants who assume risks for the benefit of scientific discovery. One important question as data sharing is expanded is: “To whom do benefits of data sharing accrue?” An equally important corollary is the question explored in an article published in the May 2023 issue of the journal Social Science & Medicine: “To whom do benefits not accrue?” Data sharing through a community-engaged research lens is examined from the perspective of helping to ensure that the communities that participate in the generation of data receive benefit from the discoveries and knowledge generated. Otherwise, a significant potential for harm can go beyond the common consideration of re-identification, including de-contextualization and misinterpretation of data and resulting findings, and disenfranchisement of participating communities. 

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Adults Who Did Not Take Prescribed Medication In Order To Reduce Costs: U.S. 2021

Data in June 2023 released from the National Center for Health Statistics show that in 2021, 8.2% of adults aged 18–64 who took prescription medication in the past 12 months reported not taking medication as prescribed due to cost. Women (9.1%) were more likely than men (7.0%) to not take prescribed medication. Adults with disabilities (20.0%) were more likely than adults without disabilities (7.1%) to not take medication as prescribed to reduce costs. Adults without prescription drug coverage were more likely to not take medication as prescribed to reduce costs compared with adults with public or private prescription drug coverage. Cost-saving measures included skipping doses, taking less medication than prescribed, or delaying filling a prescription.  Failure to adhere to treatment protocols can pose significant risks that may result in more serious illness and require additional highly costly care.  

Prevalence Of Disability By Occupation Group—-U.S. 2016-2020

Approximately 21.5 million employed U.S. adults aged 18–64 years had some form of disability in 2020. Although 75.8% of noninstitutionalized persons without disability aged 18–64 were employed, only 38.4% of their counterparts with disability were employed. According to the May 19, 2023 issue of Morbidity and Mortality Weekly Reports, individuals with disability have job preferences similar to persons without disability, but might encounter barriers (e.g., lower average training or education levels, discrimination, or limited transportation options) that affect the types of jobs they hold. The highest adjusted disability prevalences were among workers in three of the 22 major occupation groups: food preparation and serving-related (19.9%); personal care and service (19.4%); and arts, design, entertainment, sports, and media (17.7%). Occupation groups with the lowest adjusted disability prevalences were business and financial operations (11.3%), health care practitioners and technicians (11.1%), and architecture and engineering (11.0%).  

HEALTH TECHNOLOGY CORNER 

How Caregiver Speech Can Shape The Infant Brain

Decades of research have established that the home language environment, especially quality of caregiver speech, supports language acquisition during infancy. The neural mechanisms behind this phenomenon remain under studied. An investigation by researchers at the University of Texas at Dallas that was reported in the June 2023 issue of the journal Developmental Cognitive Neuroscience examined associations between the home language environment and structural coherence of white matter tracts in 52 typically developing infants from English speaking homes in a western society. MRI and audio recordings demonstrated that caregiver speech is associated with infant brain development in ways that improve long-term language progress. This study is one of the first to report significant associations between caregiver speech collected in the home and white matter structural coherence in the infant brain and is in line with prior work showing that protracted white matter development during infancy confers a cognitive advantage.  

Enabling Analysis Of Electrocardiograms As Language By A New Deep Learning Approach

Mount Sinai researchers developed an innovative artificial intelligence (AI) model for electrocardiogram (ECG) analysis that allows for the interpretation of ECGs as language. This approach can enhance the accuracy and effectiveness of ECG-related diagnoses, especially for cardiac conditions where limited data are available on which to train. A study published in the June 6 online issue of npj Digital Medicine indicates that this new deep learning model called HeartBEiT forms a foundation upon which specialized diagnostic models can be created. Researchers pretrained HeartBEiT on 8.5 million ECGs from 2.1 million patients collected over four decades within the Mount Sinai Health System. In comparison tests, models created using HeartBEiT surpassed established methods for ECG analysis. HeartBEiT has significantly higher performance at lower sample sizes compared to other models. HeartBEiT also improves explainability of diagnosis by highlighting biologically relevant regions of the EKG vs. standard CNNs.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Work Conditions And Serious Psychological Distress Among Working Adults Aged 18-64

Differences in work conditions, such as job autonomy, job insecurity, and shift work may lead to health disparities in the population. In 2021, working adults aged 18–64 who usually worked the evening or night shift (4.8%) or a rotating shift (3.9%) were more likely to experience serious psychological distress compared with day shift workers (2.3%). According to a Data Brief in April 2023 from the National Center for Health Statistics, the percentage of workers experiencing serious psychological distress increased as monthly variation in earnings increased. Serious psychological distress was higher among workers who reported difficulty changing their work schedule (4.2%) compared with those who reported it was easy or somewhat easy to change their work schedule (2.2%). Adults who worked when they were physically ill in the past three months were more likely to experience serious psychological distress (5.8%) than those who did not work when physically ill (1.9%). 

Chronic Pain Among Adults: United States, 2019-2021

Chronic pain (i.e., pain lasting ≥3 months) is a debilitating condition that affects daily work and life activities for many adults in the United States and has been linked with depression; Alzheimer disease and related dementias; higher suicide risk; and substance use and misuse. The Morbidity and Mortality Weekly Report for April 14, 2023 indicates that during 2021, an estimated 20.9% of U.S. adults (51.6 million individuals) experienced chronic pain, and 6.9% (17.1 million individuals) experienced high-impact chronic pain (i.e., chronic pain that results in substantial restriction to daily activities) with a higher prevalence among non-Hispanic American Indian or Alaska Native adults, adults identifying as bisexual, and adults who were divorced or separated. Clinicians, practices, health systems, and payers should vigilantly attend to health inequities and ensure access to appropriate, affordable, diversified, coordinated, and effective pain management care for all patients. 

HEALTH TECHNOLOGY CORNER 

Smart Surgical Implant Coatings Provide Early Warning And Prevention Of Infection

The prevalence of orthopedic implants is increasing with an aging population. These patients are vulnerable to risks from periprosthetic infections and instrument failures. Both infection and device failure are major problems with orthopedic implants, each affecting up to 10% of patients. Several approaches to fighting infection have been attempted, but all have severe limitations. Newly developed “smart” coatings for surgical orthopedic implants can monitor strain on the devices to provide early warning of implant failures while killing infection-causing bacteria, according to a manuscript published on May 5, 2023 in the journal Science Advances. University of Illinois Urbana-Champaign investigators report that the coatings integrate flexible sensors with a nanostructured antibacterial surface inspired by the wings of dragonflies and cicadas. The coatings prevented infection in live mice and mapped strain in commercial implants applied to sheep spines to warn of various implant or healing failures. 

Can Wearables Capture Well-Being?

Machine learning models applied to physiological metrics collected from wearable devices can have some predictive ability in identifying resilience states and a positive psychological construct. Applying such models, a type of artificial intelligence (AI), to data collected passively from wearable devices can identify a patient’s degree of resilience and well-being, according to investigators at the Icahn School of Medicine at Mount Sinai in New York. Findings reported on May 2, 2023 in the journal JAMIA Open  support wearable devices, such as the Apple Watch®, as a way to monitor and assess psychological states remotely without requiring the completion of mental health questionnaires. Resilience, i.e., an individual’s ability to overcome difficulty, is an important stress mitigator, reduces morbidity, and improves chronic disease management. Digital technology growth presents an opportunity to obtain a better understanding of who is at psychological risk and an improved means of tracking the impact of psychological interventions.  

DEVELOPMENTS IN HIGHER EDUCATION

Not all population subgroups in the U.S. receive equal amounts of attention in policy circles regarding how to cope with various problems that affect individuals within these groupings. An example is the presence of persistent barriers to accessing high-quality, affordable postsecondary education by currently and formerly incarcerated individuals. A positive development is that the U.S. Department of Education has developed a guide to assist colleges and universities in mitigating those barriers, moving beyond the check box on admissions applications, and providing support for these students. An original Beyond the Box report was published in 2016. The newest version, Beyond The Box 2023, became available in April of this year. It incorporates the learning and experience of the past seven years and its content benefits from views expressed by various contributors, such as formerly incarcerated students; leaders of organizations and institutions that work with these individuals; and advocates of criminal justice reform, as well as research and analysis of promising practices.  

Approximately two million Americans are incarcerated and almost 80 million individuals are living with a criminal record, The criminal justice system has a disproportionate impact on people of color and people living in poverty. Education offers a pathway to reenter society successfully, with the knowledge, skills, and credentials to obtain a good job and engage in their community. American postsecondary institutions can provide programs that are inclusive to formerly incarcerated persons. Fair and nondiscriminatory admissions processes have been adopted by many colleges and universities. Seven states have banned the use of criminal justice history questions during the college application process. In 2020, the Common Application, used by more than 900 colleges, removed the criminal justice history question from the common portion of the common application. In 2016, the Second Chance Pell Experimental Sites Initiative was launched, granting access to Pell Grants, a form of federal student financial aid, which opened the doors to higher education for tens of thousands of currently incarcerated students in a pilot program. The success of that initiative has led to forthcoming broad Pell reinstatement for all currently incarcerated students who qualify for federal financial aid and are enrolled in eligible prison education programs,      beginning in July 2023. Despite these important advances, more efforts are needed. The newest Beyond The Box Report lists key recommendations for academic institutions that plan to start or expand programs for these students. 

ASAHP And Third-Party Servicers and Institutions

The Association of Schools Advancing Health Professions (ASAHP) joined forces with several other higher education associations in sending a letter on March 29, 2023 in response to a February 15, 2023 Dear Colleague Letter (DCL), “Requirements and Responsibilities for Third-Party Servicers and Institutions” from the U.S. Department of Education. Given the potential harmful consequences that will result from the Department’s expansive new definition of a third-party servicer (TPS), without corresponding benefit, these organizations urged  the Department to rescind the current DCL and identify alternate approaches that are better targeted to the issues of concern that the government seeks to address.  

Based on comments that were submitted to the Department, it issued an update on April 11, 2023 on Third-Party Servicer Guidance. Specifically, the Department will delay the effective date of the guidance letter, and the September 1, 2023, date no longer will be in effect. The effective date of the revised final guidance letter will be at least six months after its publication to allow institutions and companies to meet any reporting requirements. The Department indicated that it does not consider contracts involving certain activities to constitute third-party servicer relationships, such as study abroad programs, recruitment of   foreign students not eligible for Title IV aid, and clinical or externship opportunities that meet requirements under existing regulations. The Department intends to remove the provision of the guidance document pertaining to foreign ownership of a third-party servicer. That provision was included in guidance issued in 2016 to protect taxpayers from uncollectable liabilities against a foreign owner. Also, public comments will be reviewed carefully on areas of confusion or concern and clarification will be considered about narrowing the scope of the guidance in several areas, including software and computer services; student retention; and instructional content.  

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, 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. 

NECESSITY OF A DEBT LIMIT INCREASE

U.S. Treasury Secretary Janet Yellen has indicated that the federal debt ceiling limit could be reached by June 1, 2023. Action will be necessary to raise that limit. As matters stand in early May 2023, however, President Joseph Biden and congressional Democrats have quite specific views on how to proceed. They favor developing a clean bill involving no restrictions on current federal government expenditures. Led by House Speaker Kevin McCarthy (R-CA), he and his Republican colleagues in that chamber have an entirely different perspective.  

House Republicans on April 25, 2013 introduced the Limit, Save, Grow Act of 2023 (H.R. 2811). It passed the next day on a vote of 217-215. This bill increases the federal debt limit and decreases spending. It also repeals several energy tax credits; modifies the permitting process and other requirements for energy projects; expands work requirements for the Supplemental Nutrition Assistance Program (SNAP) and other programs; and nullifies regulations for the cancellation of federal student loan debt. Specifically, the bill: 

· Suspends the debt limit through March 31, 2024, or until the debt increases by $1.5 trillion, whichever occurs first;

· Establishes discretionary spending limits for the 10-year period FY2024-FY2033 that include decreases in discretionary expenditures;

· Rescinds certain unobligated funds that were provided to address COVID-19 and to the Internal Revenue Service;

· Nullifies certain executive actions and regulations for cancelling federal student loan debt and implementing an income-driven repayment plan for student loans;

· Repeals or modifies tax credits for renewable and clean energy, energy efficient property, alternative fuels, and electric vehicles;

· Establishes new work requirements for Medicaid and expands the work requirements for SNAP and the Temporary Assistance for Needy Families (TANF) program; and

· Requires major federal rules (e.g., rules likely to result in an annual economic effect of at least $100 million) to be approved by Congress before they take effect. 

Two outcomes appear certain. First, the Senate, which is controlled by Democrats, would never include this package. Second, even if they do so, President Biden will not sign it into law. All previous attempts to increase the federal debt level have been successful. Failure to do so might possibly produce some unfavorable results, such as an increase in interest rates, the onset of a recession, and delays in sending monthly checks to Social Security beneficiaries. Higher education also could be impacted adversely, e.g., the student loan repayment pause implemented because of COVID-19 could be ended immediately. 

DATA UNDERGIRD HEALTH POLICY FORMATION

Valid and reliable data are a sine qua non of constructive health policy. A paper in the April 27, 2023 issue of the New England Journal of Medicine on the topic of advances in artificial intelligence for infectious-disease surveillance acknowledged when nurse and statistician Florence Nightingale developed her innovative “rose diagram” of preventable deaths in the Crimean War (April 1854 to March 1855). Despite heavy opposition from her British medical and military superiors, her efforts revolutionized data-driven disease surveillance. An excellent summary of her achievements is conveyed in an article by Lee Brasseur in the Spring 2005 issue of the journal Technical Communication Quarterly. 

Her figures consisted of wedges arranged around a center with each wedge representing by its area the amount of mortality for the period to which it refers. They were called rose diagrams, so called because of their shape, which resembles that flower. The illustrations are remarkable not only in being able to communicate this kind of comparative argument, but also because of their ability to show the progression of the war as revealed both through their circular shape and their textual features. Clearly, nothing like Nightingale’s rose diagram had been seen previously. Not only was her approach unique, it compares favorably with two famous visualizations of that same period: Charles Joseph Minard’s portrayal of wartime mortality while plotting the strength of the Napoleonic Russian Campaign as it progressed through the Russian winter and John Snow’s production of a map displaying epidemiological data leading to the discovery of the source of a cholera epidemic at the famous Broad Street Pump in London, England. 

Many important statistical advances have occurred since then and the U.S. leads the world in the production of important data pertaining to a broad spectrum of human and animal existence. As described in the May 2023 issue of The American Journal of Clinical Nutrition, the 1956 National Health Survey Act authorized federal agencies to collect statistics for a variety of health issues. This law created the U.S. National Health Survey Program, a component of which was the National Health Examination Survey (NHES). Nutritional assessment was added to NHES in 1971 and the survey was renamed NHANES (National Health and Nutrition Examination Survey) to assess health and nutritional status of adults and children in this nation. It operates primarily out of mobile examination centers (MECs) that travel to selected sites to obtain a representative sample of the U.S. population.  

Presently, NHANES is at a key crossroads. The impact of years of inflation on the survey’s stagnant budget has undercut activities to meet the future. The potentially game-changing nature of newer challenges cannot be avoided. Supporters believe that a study by the National Academies of Sciences, Engineering, and Medicine (NASEM) to set the stage for the future of NHANES, i.e., to provide an actionable framework, is a critical and prudent step forward. Also, maintaining the status quo and failing to adapt to emerging challenges cannot be an option for a survey that is so vital to the nation’s health and wellbeing. 

PREPARING THE FEDERAL FY 2024 BUDGET

Fiscal Year 2024 commences on October 1 of this year for the federal government. The stage is set every year by submission of a budget by the president to Congress for its consideration. Regardless of which party controls the White House, legislators in both chambers typically every year see little concordance between what the nation’s chief administrator wants and what eventually will materialize in a final spending package.  

This year may prove to be a faithful rendition of what characteristically unfolds annually. President Biden submitted a budget proposal that is widely viewed as being highly unlikely to reach fruition. Roadblocks occur along the way, deadlines are rarely met, and it is customary each October 1 for a series of short-term resolutions to be created as a means of enabling the government to continue to function. Now that Congress is divided with Republicans controlling the House and Democrats the Senate, the pattern can be expected to manifest itself once again in 2023. The main features of the Administration’s proposed budget include an overall $6.9 trillion that involves a 3.3% increase in defense spending and a 6.5% increase for nondefense discretionary programs, Taxes would be increased by $5.5 trillion and the federal deficit would decline by more than $2 trillion over the next 10 years. The U.S. Department of Health and Human Services would see an 11.5% increase to its overall budget, including $144.3 billion in discretionary and $1.7 trillion in mandatory proposed budget authority.  

The solvency of the Medicare program continues to be worrisome. President Biden proposes to increase the Medicare tax rate from 3.8% to 5% on earned and unearned income above $400,000, and also eliminate a tax loophole that allowed certain business owners to avoid paying Medicare taxes on a portion of their income. A budget element that always attracts much attention is “earmarks.” Legislators are especially fond of them because it makes it possible to spend money on pet endeavors in states and congressional districts that curtail the ability of the Executive Branch to manage the fund allocation process. Representative Robert Aderholt (R-AL), who heads the House Appropriations Labor-Health and Human Services-Education Subcommittee, has decided to ban these congressionally directed spending requests from his panel’s FY 2024 appropriations bill.  

Apart from appropriations, Congress is working on other matters pertaining to health care. One possibility being considered is to prohibit federal agencies from using quality-adjusted life years as a metric to evaluate the cost-effectiveness of drugs and treatments. A concern is that the metric is discriminatory because it undervalues the benefits that therapies provide to individuals who have disabilities. The House Energy and Commerce Committee advanced The Protecting Health Care for All Patients Act (H.R. 485) by a vote of 27-20 along party lines. A concern is that the measure may have the potential to disrupt implementation of the Inflation Reduction Act’s Medicare drug price negotiation provisions.

DEVELOPMENTS IN HIGHER EDUCATION

In his allegorical novel Animal Farm, George Orwell stated that “All animals are equal, but some animals are more equal than others.” The domain of higher education illustrates this maxim all too well. Although some institutions are blessed with thousands of eager applicants each academic year, that luxury does not function across the board of higher education. Based on public polling data, a decline in the number of high school graduates in recent years is an example of a change that has been accompanied by a sentiment, which indicates that some students and their families are less enamored of the value of a college degree than they were only a few years ago. A consequence is that a drop off in the number of applicants at some institutions may result in the necessity of either reducing the number of faculty and staff; eliminating programs in the humanities deemed unlikely to lead to jobs after graduation that are commensurate with the financial costs of obtaining a degree, cutting the scope of campus services offered, or closing the doors completely.

A report issued by the National Student Clearinghouse Center on March 29, 2023 indicates that community college enrollment is starting to grow in spring 2023 (+2.1%), fueled by strong growth among dual enrollees (age 17 and under) and freshmen. Community college growth is occurring across all campus settings while undergraduate enrollment is increasing only at suburban campuses for four-year institutions. Overall undergraduate enrollment was steady this spring (+0.2%), with only the public four-year sector experiencing undergraduate enrollment declines. Total enrollment (graduate and undergraduate enrollment combined) has remained unchanged compared to spring 2022. Enrollment growth continues to be the strongest in certificate programs at both the undergraduate (+5.5%) and graduate (+4.6%) levels. Associate and bachelor’s degree seeking students had more muted enrollment changes (+0.3% and -0.6%, respectively). Undergraduate men, hit particularly hard at the beginning of the pandemic, are now seeing enrollment growth (+0.7%), while the enrollment slide continues for women (-0.9%). Latinx students were the only major racial and ethnic group to show enrollment increases (+0.9%).

Public Hearings On Future Rulemaking Sessions

The U.S. Department of Education (USDE) on March 23, 2023 announced that it will hold virtual  public hearings on April 11, 12, and 13, 2023, to obtain views on future rulemaking sessions. These hearings begin the process of considering new USDE regulations. Following the hearings, an agenda for the rulemaking process will be finalized and nominations for negotiators to serve on the negotiated rulemaking committee will be solicited. The Department is planning three, four-day sessions of negotiated rulemaking to begin this fall. Potential topics for rulemaking are: institutional eligibility, including State authorization; the definition of distance education as it pertains to clock hour programs; and reporting students who enroll primarily online. Individuals who would like to comment at the public hearings must register by sending an email message to negreghearing@ed.gov. Individuals who wish to view the hearings without providing comment must register to observe. The public can provide written comment for 30 days following the official posting.  

Student Loan Forgiveness

Led by Senator Bill Cassidy (R-LA), ranking member for the Health, Education, Labor and Pensions Committee, he and several Republicans in that chamber on March 27, 2023 introduced a Congressional Review Act (CRA) resolution to overturn President Biden’s student loan forgiveness plan, which is under review by the U.S. Supreme Court where a decision is expected to be made in coming months. The plan is aimed at forgiving up to $20,000 for borrowers with federal loans. The Congressional Budget Office estimated that the proposal would cost about $400 billion over the next 30 years. The CRA enables      Congress to review and overturn any regulations created by a federal agency. The Government Accountability Office (GAO) has determined that the plan by President Biden is subject to the resolution. In order for the CRA to go into effect, it will require approval by both the House and the Senate, and then be signed by the President. It is likely that he would veto the initiative if it reaches that stage.

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.