DEMOGRAPHY AS A USEFUL HARBINGER

The accumulation of population data produces benefits that accrue both to individuals and society. Fertility and immigration rates provide an indication that population growth is moving in a positive direction. The volume of high school graduates each year enables higher education administrators to develop student enrollment projections. The size of the overall workforce makes it possible to assess the amount of tax revenues that can be generated and the extent to which they suffice to pay for health and social benefits of individuals who are not employed. Life expectancy data make it possible to determine how many and what kinds of clinicians will be needed to meet population health care needs.

The United States has an impressive record of producing valuable data, but there continues to be opportunities for making improvement in the health realm. For example, according to a paper in the October 2023 issue of the journal Demography, despite extensive research on cognitive impairment and limitations in basic activities of daily living, no study has investigated the burden of their co-occurrence (co-impairment). Using the Health and Retirement Study data and incidence-based multistate models, researchers studied the population burden of   co-impairment using three key indicators: mean age at onset, lifetime risk, and health expectancy. Patterns were examined by gender, race, ethnicity, nativity, education, and their interactions for U.S. residents aged 50–100. Moreover, the analysis included looking at what fractions of racial, ethnic, and nativity disparities in co-impairment are attributable to inequalities in educational attainment.  

Results reveal that an estimated 56% of women and 41% of men aged 50 will experience co-impairment in their remaining life expectancy. Men have an earlier onset of co-impairment than women (74 vs. 77 years), and women live longer in  co-impairment than men (3.4 vs. 1.9 years). Individuals who are from racial and ethnic minority groups, and lower educated, especially those experiencing intersecting disadvantages, have substantially higher lifetime risk of co-impairment, earlier co-impairment onset, and longer life in co-impairment than their counterparts. As much as 75% of racial, ethnic, and nativity disparity is attributable to inequality in educational attainment.  

Life expectancy at older ages has increased in the United States, contributing to the expansion of the older population. Adults aged 65 and older constituted 17% (56 million individuals) of the total U.S. population in 2020, but are expected to represent 22% (81 million individuals) of the population by 2040. Population aging poses a challenge because cognitive function and the ability to carry out basic activities of daily living decline as adults age, often preventing independent living. The most disadvantaged subpopulations, which are likely to be the least economically resourced, bear the greatest burden of co-impairment. Hence, policy implications include not just interventions on proximate determinants of health, such as promoting positive health contexts (e.g., increasing social connectedness), but also providing support for these vulnerable groups (e.g., expanding coverage of health and long-term care insurance).

PATIENT UNDERSTANDING IN CLINICAL PRACTICE

An essential aspect of enabling patients to make autonomous decisions in a health care setting is that they must be in a favorable position to understand relevant information. Yet, there exists a lack of consensus on how the term understanding should be defined or assessed in this context, despite the fact that in practice clinicians regularly are required to judge whether patients have understood health information being conveyed. Current accounts of patient decision-making often focus on the information that needs to be disclosed to patients to support their autonomous decision-making. Far less attention has been afforded to questions about how to determine whether patients have understood the information that is disclosed to them. Theoretical approaches to the concept of understanding in this context, and practically useful frameworks for assessing it, are considered to be lacking. In a paper appearing in the October 2023 issue of the Journal of Evaluation in Clinical Practice, a number of hypothetical clinical situations are employed to explore the conditions that are required for a patient to understand information in medical decision-making adequately.  

The author draws upon philosophical literature to examine how understanding might be defined and assessed in a medical context. Initially, the relationship between understanding and autonomy is outlined prior to using hypothetical clinical scenarios to explore which elements might be necessary for patient understanding. An argument is forwarded that an account of patient understanding must consider issues relating to the definition and operationalization of grasping, the requirement for factivity, and the concept of degrees of understanding. Finally, it is suggested how clinicians should assess understanding in practice. Drawing upon the wider philosophical literature, the following criteria are proposed that are necessary for understanding in a medical context: patients must (1) grasp a body of information that (2) reasonably reflects a responsible body of medical professionals' best estimate of the truth, (3) to a degree which meets a context-specific threshold. These criteria may prove to be beneficial in guiding assessments of patient understanding in clinical practice. 

EXPLICIT AND IMPLICIT: ABLEISM OF DISABILITY PROFESSIONALS

Ableism has been defined as “stereotyping, prejudice, discrimination, and social oppression toward individuals with disabilities.” It is considered to be quite common in society in ways that significantly hinder the health, well-being and quality of life of patients who must cope with the negative effects of  being perceived in this manner. As described in a manuscript published in the October 2023 issue of the periodical Disability and Health Journal, ableism not only describes the discrimination that persons with a disability face, but also compulsory able-bodied/mindness, where nondisabled bodies/minds are favored, and all others are marked as deviant. Society, including not only relations between individuals, but also environments, policies, and social practices, is structured accordingly, frequently resulting in various forms of oppression. Thus, in order to reduce ableism, it is critical to conduct research exploring the factors that create, reproduce, and contribute to ableist ideas and actions. The aim of a study described in an article in that journal was to examine the explicit (conscious) and implicit (unconscious) disability attitudes of disability professionals.  

Between October 2021 and February 2023, disability professionals (n = 417) completed the Symbolic Ableism Scale (SAS) and the Disability Attitudes Implicit Association Test (DA-IAT). The following research questions were addressed: (1) What are disability professionals' explicit attitudes towards disability? (2) What are disability professionals' implicit attitudes towards disability? (3) What is the relationship between disability professionals' explicit and implicit disability attitudes? and (4) What sociodemographic factors correlate with disability professionals’ explicit and implicit disability attitudes? In the sample, 77.24% of disability professionals explicitly preferred individuals without a disability and 82.03% implicitly. Most commonly, disability professionals were symbolic ableists (37.8%). Race, political orientation, and job type correlated with disability professionals’ explicit attitudes, while disability, gender, and job type correlated with their implicit attitudes. A conclusion of this investigation is that ableism cannot be eradicated until disability professionals look inward and rid themselves of negative attitudes. Until that change occurs, these practitioners will continue to do a disservice to the very patients for whom they are supposed to be furnishing clinical assistance. 

OBTAINABLE RESOURCES

BIBLIOGRAPHIC ESSAYS ON THE HISTORY OF PANDEMICS 

In 1913, historian of science George Sarton created what has become the Isis Current Bibliography of the History of Science (IsisCB). For the last 110 years, the journal Isis has included a comprehensive survey of the recent work in the history of science and allied fields, first in each issue and later as a full yearly supplement. Now the basis of a free online search tool called IsisCB Explore, the IsisCB continues to serve as an indispensable reference for scholars and students. “Bibliographic Essays on the History of Pandemics” is a special issue of the IsisCB published in September 2023. It features 19 essays along with accompanying bibliographies of go-to sources in the field. All essays and bibliographies in this issue are free to read. Conceived in 2020 as a response to the COVID-19 pandemic, the special issue was intended to serve as a key resource for historians of science with applications extending beyond the discipline. The issue is grouped into several thematic clusters that draw vital connections between historical and emerging themes in global health, including a geographically focused cluster covering Asia, Europe, and Latin America; a pre-modern cluster with essays on the Ancient Mediterranean and Islamicate worlds; as well as a cluster focusing on other pandemic diseases in history. This resource can be obtained here. 

HIDING IN PLAIN SIGHT: THE HEALTH CARE GENDER TOLL 

Out-of-pocket health care costs for employed women in the United States are estimated to be $15 billion higher per year than for employed men, exacerbating gender wage disparities. This financial burden on women persists even when excluding maternity-related services. How can businesses and health insurers help close the cost gap and address gender bias in health care? An analysis from the firm Deloitte reveals that women across all age groups from 19 to 64 experience disproportionately higher out-of-pocket medical expenses compared to men, even when excluding pregnancy-related services. On average, female employees under single coverage incur approximately $266 more in annual out-of-pocket costs than their male counterparts, constituting over an 18% increase. This gender-based financial challenge highlights the need for businesses to scrutinize benefit coverage to make health care more affordable for female employees. Deloitte’s health actuarial team has delved into the average benefit design’s consequences on women’s financial outlays when accessing health care services. Findings suggest that health insurance products inadvertently may create an income gap for working women, compounding the effects of the well-documented gender wage disparity. This dual burden of elevated health care expenditures and the gender wage gap forces employed women into difficult choices between necessary care and affordability. The report is available here.

INTERGENERATIONAL POVERTY IN THE UNITED STATES 

Reducing intergenerational poverty would yield a high payoff for children and the entire nation, according to a new report from the National Academies of Sciences, Engineering and Medicine. The document examines key drivers of intergenerational poverty in the U.S. and evidence-based policies most likely to lessen the chances that children living under such circumstances will experience poverty as adults. Poverty during childhood can lead to lasting harmful effects that compromise not only children’s health and welfare, but also can hinder future opportunities for economic mobility, which may be passed on to future generations. This cycle of economic disadvantage weighs heavily not only on children and families experiencing poverty, but also the nation, reducing overall economic output and placing increased burden on the educational, criminal justice, and health care systems. The report assesses existing research on the effects on intergenerational poverty of income assistance, education, health, and other intervention programs and identifies evidence-based programs and policies that have the potential to reduce the effects of the key drivers significantly. The report can obtained here.  

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Deaths: Final Data for 2020

In 2020, a total of 3,383,729 deaths were reported in the United States. The age-adjusted death rate was 835.4 deaths per 100,000 U.S. standard population, an increase of 16.8% from the 2019 rate. Life expectancy at birth was 77.0 years, a decrease of 1.8 years from 2019. Age-specific death rates increased from 2019 to 2020 for age groups 15 years and over and decreased for age group under one year. Many of the 15 leading causes of death in 2020 changed from 2019. COVID-19, a new cause of death in 2020, became the third leading cause in 2020. The infant mortality rate decreased 2.9% to a historic low of 5.42 infant deaths per 1,000 live births in 2020. Conclusions: In 2020, the age-adjusted death rate increased and life expectancy at birth decreased for the total, male, and female populations, primarily due to the influence of deaths from COVID-19. These data appear in the September 22, 2023 issue of National Vital Statistics Reports.

Cause-Specific Mortality By County, Race, And Ethnicity In The U.S., 2000-19 

Disparities in mortality among racial-ethnic groups are ubiquitous, occurring across locations in the U.S. and for a wide range of health conditions. According to an article in the September 23, 2023 issue of the journal Lancet, there is an urgent need to address the shared structural factors driving these widespread disparities. From 2000 to 2019, across 3,110 U.S. counties, racial-ethnic disparities in age-standardized mortality were noted for all causes of death considered. Mortality was substantially higher in the non-Hispanic American Indian or Alaska Native (AIAN) population (all-cause mortality 1028.2 [95% uncertainty interval 922.2-1142.3] per 100,000 population in 2019) and Black population (953.5 [947.5-958.8] per 100,000) than in the White population (802.5 [800.3-804.7] per 100,000), but substantially lower in the Asian population (442.3 [429.3-455·0] per 100, 000) and Latino population (595.6 [583.7-606.8] per 100 000). This pattern was found for most causes of death.  

HEALTH TECHNOLOGY CORNER 

An Overview Of The Effect Of Telehealth On Mortality: A Systematic Review Of Meta-Analyses

Implementation of telehealth services aims to augment health care positively so that patients receive the most appropriate treatment using the right method and technology, all within a timely manner. While it is not appropriate for all health care to be diverted to telehealth, a review in the October 2023 issue of the Journal of Telemedicine and Telecare demonstrates that for the five disciplines included (cardiovascular, neurology, pulmonary, obstetrics and intensive care), telehealth interventions do not detrimentally affect the mortality rates for patients. Safety has to be considered according to specific clinical discipline, disease state, patient type, and application. As telehealth becomes integrated in mainstream health services, the same quality procedures should apply to monitor clinical effectiveness, user experience, and quality of care. The evidence from this review can be used by decision makers, in conjunction with other disease-specific and health economic literature, to formulate and guide telehealth implementation plans.

Multicellular Bioprinted Skin Facilitates Human-Like Skin Architecture In Vivo

Skin regeneration has long been studied with hopes of providing burn victims, wounded warriors, and those with skin disorders opportunities at complete healing. A research paper published on October 4, 2023 in Science Translational Medicine presents a significant breakthrough in the area of skin regeneration and wound healing by researchers at the Wake Forest Institute for Regenerative Medicine. Available grafts often are temporary, or if permanent, have only some elements of normal skin, which often have a scarred appearance. The creation of full thickness skin has not been possible to date. This study involved the bioprinting of all six major primary human cell types present in skin combined with specialized hydrogels as a bioink. Multi-layered full thickness skin was created which contained all three layers present in normal human tissue: epidermis, dermis, and hypodermis. The investigation shows the successful development of bioprinted skin that can accelerate wound healing and provide optimism for complete wound recovery.

DEVELOPMENTS IN HIGHER EDUCATION

The Biden administration on October 4, 2023 announced that an additional 125,000 Americans have been approved for $9 billion in debt relief through adjustments the U.S. Department of Education has made to income-driven repayment (IDR) and Public Service Loan Forgiveness (PSLF), and granting automatic relief for borrowers with total and permanent disabilities. Today's announcement brings the total approved debt cancellation by the Administration to $127 billion for nearly 3.6 million borrowers. The following approvals are in effect: 

· $5.2 billion in additional debt relief for 53,000 borrowers under Public Service Loan Forgiveness programs.

· Nearly $2.8 billion in new debt relief for nearly 51,000 borrowers through fixes to income-driven repayment plans. These debtors have been in repayment for 20 or more years, but never acquired the relief to which they were entitled.

· $1.2 billion for nearly 22,000 borrowers who have a total or permanent disability and have been identified and approved for discharge through a data match with the Social Security Administration.

Earlier this year, the Administration launched the most affordable student loan repayment plan, SAVE, which makes many borrowers' monthly payments as low as zero dollars and prevents balances from growing because of unpaid interest. In the wake of the Supreme Court decision on the Administration's original student debt relief plan, the Administration is pursuing an alternative path to debt relief through negotiated rulemaking under the Higher Education Act. The Education Department took an important step forward in the negotiated rulemaking, announcing individuals who will serve on the negotiating committee and releasing an issue paper to guide the first negotiating session. The paper requests the committee to consider how the Administration can help borrowers, including borrowers whose balances are greater than what they originally borrowed, who would be eligible for relief under existing repayment plans, but have not applied, and who have experienced financial hardship on their loans that the current loan system does not address.

Protecting Consumers From Unaffordable Student Debt

The Administration released final regulations that establish a set of safeguards against unaffordable debt or insufficient earnings for postsecondary students. The rule has two key components: 

· A revitalized and strengthened Gainful Employment (GE) rule to protect approximately 700,000 students a year from career training programs that leave graduates with unaffordable loan payments or earnings no better than what could be obtained without pursuing a postsecondary education earns in their respective states. 

· A new Financial Value Transparency (FVT) framework will give students in all programs the most detailed information about the net costs of postsecondary programs and the financial outcomes that can be expected. Prospective students will be aided in understanding potential risks involved in their program choices by requiring them to acknowledge viewing this information before enrolling in certificate or graduate programs whose graduates have been determined to face unaffordable debt.

The Department estimates that the final rule will protect nearly 700,000 students annually who otherwise would enroll in one of nearly 1,700 low-performing programs. The final rule is available here.

HEALTH REFORM DEVELOPMENTS

Currently in its 14th year of existence, the Patient and Protection Affordable Care Act (P.L. 111-148) represented a monumental effort to produce a major transformation of health care in the United States. The Center for Medicare & Medicaid Innovation (CMMI) was created by this legislation. It conducts pilot programs, known as models, that test new ways to deliver and pay for health care in Medicare, Medicaid, and the Children’s Health Insurance Program, with the goal of identifying approaches that reduce spending or improve the quality of care. A new report prepared at the Congressional Budget Office in September 2023 presents findings from an analysis of CMMI’s activities during the first decade of operation and uses those findings to update its projections of CMMI’s effects on federal spending. The report explains changes to CBO’s analytic method and discusses the agency’s revised approach to estimating the effects of legislative proposals that would change CMMI’s models or operations. CBO previously estimated that CMMI’s activities would reduce net federal spending, but now estimates that they increased that spending during the first 10 years of the center’s operation and will continue to do so in its second decade. 

A State Scorecard On Long-Term Care Services And Supports

The 2023 Long-Term Services and Supports Scorecard (LTSS) developed by AARP is a compilation of state data and analysis based on a new vision of a high-performing system. Released every three years, the Scorecard uses data from a wide range of sources to describe how state LTSS systems are performing. The intention is to identify strengths and weaknesses in state systems to spark and inform the development of actionable solutions at the local, state, and national levels— solutions that respond in meaningful ways to individual preferences and family choices and care needs as well as to new pressures and challenges. 

The latest version of the scorecard released on September 28, 2023 finds long-term care for older adults and individuals with disabilities in the United States profoundly inadequate. Long-term care is evaluated across five different dimensions: affordability and access; choice of setting and provider; safety and quality; support for family caregivers; and community integration. It also includes several new measures of racial equity. The scorecard finds major deficiencies in every state, especially related to support for family caregivers, the long-term care workforce, equity in nursing homes, and emergency preparedness, Minnesota (1st) and Washington State (2nd) outperformed all other states. Both offer particularly strong supports for family caregivers as well as varied choice of care providers and long-term care settings. The lowest-scoring states were in the Southeast, with Alabama and West Virginia ranking 50th and 51st, respectively. 

Financing Struggles Facing Older Medicare Enrollees                                            

A common misconception is that once beneficiaries are eligible for Medicare, they no longer need to worry about medical bills or choosing a health plan. Individuals electing to enroll in traditional Medicare tend to rely on supplemental coverage to help meet the cost-sharing payments and deductibles that are required. This supplemental coverage can be either a Medigap plan that they purchase, coverage from a union or former employer, or coverage from Medicaid. Some beneficiaries in traditional Medicare cannot afford to buy a Medigap plan or are restricted from purchasing one, do not qualify for Medicaid, or lack access to employer or union-based coverage. Beneficiaries who choose to be covered through a Medicare Advantage plan — private insurance plans that contract with the federal government to provide Medicare-covered benefits — can have lower cost-sharing requirements and some coverage of benefits not included in traditional Medicare. These plans, however, typically use tools, such as prior authorization requirements, to manage enrollees’ use of services, which can pose barriers to care. 

A data brief issued on September 18, 2023 from the Commonwealth Fund indicates that about one in five adults age 65 and older with Medicare (19%) were underinsured, meaning their out-of-pocket expenses are high relative to their income. More than one in five (23%) adults age 65 and older with Medicare reported that they struggled to afford their premiums. For those with incomes under twice the federal poverty level (FPL), two of five (39%) reported struggling to afford premiums.   

DEUS EX MACHINA REDUX

Similar to previous occasions, fiscal year 2023 was drawing to a close on September 30 as the prospects of producing legislation to avoid a federal government shutdown the next day appeared to be quite slim. Then, to the considerable surprise of many skeptics, House Speaker Kevin McCarthy (R-CA) yanked the proverbial rabbit out of a hat by bringing the bipartisan stopgap spending bill, H.R. 5860, to the floor. It passed 335-91, with 90 Republicans and one Democrat voting in opposition. The legislation made it possible to extend FY 2023 funding through November 17 in the new fiscal year beginning October 1. Next, on a vote of 88-9, the Senate accepted the House version of the bill even though it eliminated funding for Ukraine and a provision that would raise the amount of pay for Members of Congress. Late September 30, President Joseph Biden signed the measure into law.  

Unfortunately for Representative McCarthy, those 90 Republicans in opposition included eight members of a conservative group known as the Freedom Caucus in his political party who swiftly took action to remove him from his position as Speaker. Almost immediately, he faced a motion to vacate the chair. Headed by Representative Matt Gaetz (R-FL), they opposed a bipartisan approach to government funding and sought to enact steep budgetary cuts. They blamed the Speaker for failing to achieve these more desirable outcomes. He was ousted on a 216-210 vote that included those eight members. 

For the nonce, Representative Patrick McHenry (R-NC) will serve as speaker pro tempore until the Republican conference decides whom to select as a permanent replacement to fill the vacated position. Presently, it is unclear if he has enough support from that conference to begin negotiations with the Senate regarding 12 major appropriation bills awaiting enactment. Thus far, the House has passed four of those spending bills while the Senate Appropriations Committee has approved all 12 of them, but none has passed the full Senate. 

Congress often is criticized for being too polarized. Yet, legislative progress continues to take place regarding other matters that are important. As an illustration, all too often in the health domain insufficient attention is paid to prominent health workforce concerns. The Senate Health, Education, Labor and Pensions (HELP) Committee advanced a bipartisan primary care and health care workforce package (S. 2840) on September 21 by a vote of 14-7. Chairman Bernie Sanders (I-VT) joined forces with Senator Roger Marshall (R-KS) as co-authors of this bill. Senators Mike Braun (R-IN) and Lisa Murkowski (R-AK) combined with Committee Democrats in support of the measure. The Bipartisan Primary Care and Health Workforce Act includes nearly a $2 billion annual increase in mandatory funding for community health centers. The total will be $5.8 billion annually over a three-year period. Mandatory funding for the National Health Service Corps would be tripled from $310 million to $950 million annually for three years. If enacted, another beneficiary would be the provision of $1.5 million in mandatory funding over the next five years for the Teaching Health Centers Graduate Medical Education program.  

WHEN LINGUISTIC CLARITY IS LACKING

Periodically, this newsletter serves as a vehicle for discussing how terminology inexactitudes can have a detrimental impact on health care quality. A recent example appeared in the September 26, 2023 issue of the journal Neurology. Brain health is crucial to optimizing both the function and well-being of every individual at each stage of life and is key to both personal and social progress. As a concept, brain health is complex and requires a multidisciplinary collaborative approach involving many professional and public organizations to bring into effect meaningful change. The term brain health is defined, however, in many ways or not at all, but used with profligate ease.

Consequently, there is a need to anchor multiple definitions to a common, comprehensive, and comprehensible explanation since brain health usually means physical cerebral health to neurologists, mental health typically denotes healthy behavior to psychiatrists, and social health seldom is connected to cerebral or mental health. Moreover, it is unlikely that an organization developing a definition will relinquish it, thereby dooming reconciliation through negotiation.

On a much wider scale, a similar degree of conceptual opacity characterizes the word “health.” According to an article in the September 2023 issue of the periodical The Milbank Quarterly, because of this opaqueness, health tacitly is defined narrowly as the absence of disease. The result is a perpetuation of a biomedical paradigm in health care with a focus on diagnosing and treating disease. This tacit definition yields poor investment in the inherent health potential of individuals relative to drugs and technology, thus fostering a misalignment between the goals of health care and the goals of individuals, communities, public health, and society.

A biomedical model is reflected in health care billing that generally requires coding for a recognized disease, billing for procedures that address diseases, and in most quality measures that address either processes or diseases over short horizons, i.e., 12-month time frames. Under the cloud of conceptual opacity, health care defaults to a disease-oriented model to the detriment of patients, society, and the promotion of meaningful health equity.

Instead, promoting health in health care requires investment in human capabilities and potential by enabling individuals to manage their health and by supporting their autonomy, competence, and healthy relationships while buttressing equity in social determinants of health (SDOH) that are critical to promoting equity in human potential and well-being. This approach will require a paradigmatic and cultural shift with implications for health care leadership, organizational culture, human development, funding allocation, care models, training, measurement, accountability, and health equity. Doing so will necessitate organizational and delivery reforms, systems for bidirectional relationships with community-based human service organizations, intersectoral partnerships to promote community health, and advocacy for “health equity in all policies.” 

SORITES PARADOX IN HEALTH CARE DELIVERY OVERUSE AND UNDERUSE

A proposition is advanced that health care around the globe suffers from both underuse (undertreatment and undertesting) and overuse (overtreatment and overtesting) that have persisted for decades. Studies have identified many drivers of suboptimal care, generally classified into three categories: (a) economic incentives affecting clinician behavior; (b) professional knowledge, bias, the uncertainty inherent in clinical decision-making; and (c) failure to include patients to capitalize on the power of human relationships. Nonetheless, these drivers only partially explain the persistence of suboptimal use. In a paper appearing in the September 2023 issue of the Journal of Evaluation in Clinical Practice, an argument is proposed that overuse and underuse of services are an inherent consequence of the nature of the relationship between scientific evidence and decision-making. Evidence about diagnosis or health outcomes exists on the probability continuum (from impossibility to virtual certainty), while decisions are categorical (e.g., treatment is or is not recommended).  

For example, risk for heart disease can range from close to zero (young, healthy individuals) to 100% when clinically manifested as myocardial infarction. To help reduce risk of heart disease, the American College of Cardiology and American Heart Association (ACC/AHA) recommend that treatment is warranted if the risk ≥7.5% over 10 years. If the estimated risk is below this threshold, treatment should not be recommended. Doing so would reflect overuse/overtreatment. Conversely, not recommending treatment would constitute underuse/undertreatment. So, why not administer statins at 7.4% (or, 7.3%, 7.2% … 0.01%)? The problem relates to an ancient epistemological puzzle called the Sorites paradox, also known as “little-by-little arguments.” Sorites in the Greek language means heap while paradox reflects challenges in defining clear boundaries between borderline cases of the quantities of interest. At which point does the collection of grains become large enough to be called a heap and small enough to be classified as a few scattered grains of sand? The Sorites paradox abounds. Because clinicians use scientific evidence (that exists on a continuum) but make categorical (yes/no) decisions based on numerical thresholds, the Sorites paradox is unavoidable in practice. A possible approach to a solution is to apply threshold decision models, which the authors discuss.

ENHANCING INTERCULTURAL COMMUNICATION SKILLS IN HEALTH CARE

Immigration continues to contribute to an increase in diversity in the U.S. population. Consequently, the enhancement of intercultural health communication skills among clinicians represents an increasingly challenging task. As noted in a manuscript in the October 2023 issue of the journal Patient Education and Counseling, previous research abundantly has indicated that medical consultations between health care providers and migrant and ethnic minority patients tend to lead to worse communication processes and outcomes compared to those between health care providers and patients belonging to the same majority groups. For instance, migrant and ethnic minority patients ask fewer questions, have a reduced understanding of their illness, are less adherent to treatment recommendations, and have higher rates of misdiagnoses compared to ethnic majority patients. Also, health care providers have indicated a need for more training to acquire the cultural skills and knowledge required to enable better care delivery to migrant patients. Factors contributing to the challenges in intercultural communication are individual patient-related, such as specific health and illness beliefs; individual provider-related factors, such as a conscious or unconscious bias toward minority patients; and social and system-related factors, such as a lack of interprofessional dialogue and the financial resources required to call in professional interpreters to mitigate possible language barriers.  

The authors elaborate on three main recommendations based on theoretical and empirical knowledge about how to train health care providers adequately in intercultural communication. First, they give an overview of the fundamental skills in which health care providers should receive training, such as self-awareness and adaptability. Second, they briefly discuss how such training should be delivered, and focus on different language support methods, including those that work with different types of interpreters and digital tools. Third, they discuss how within-group differences can be taken into account to prevent stereotyping. To illustrate these recommendations, certain examples of existing good practices and interventions are provided. A conclusion is that there is a need for clearer recommendations for affirmative action, guidelines, policy, and support for the topic of diversity sensitivity in health care, such as evidence-based interventions, than is currently the case. 

OBTAINABLE RESOURCES

WHO Traditional Medicine Global Summit 2023 

The first WHO Traditional Medicine Global Summit  “Towards health and well-being for all” was held in Gandhinagar, Gujarat, India, on 17-18 August 2023, to look anew at the application of rigorous scientific methods to unlock the vast potential of traditional, complementary, and integrative medicine (TCIM) amidst important challenges and opportunities to realize universal health coverage and promote health and well-being for individuals and the planet. Participants in the Summit, coming from all WHO regions, included a range of stakeholders: from health and TCIM practitioners; civil society representatives and Indigenous Peoples; to health policy and decision-makers and government officials from the G20 and other countries. Based on the research and evidence-informed discussions and initiatives presented in the Summit’s five plenary and six parallel sessions, participants endorsed the outcomes of the Summit in a meeting report: The Gujarat Declaration. The document sets out an action agenda towards the implementation of evidence-based TCIM interventions and approaches in support of the goal of universal health coverage and health-related Sustainable Development Goals, among others, and the application of science, technology, innovation, and knowledge exchange to validate and unlock, as appropriate, the contribution of TCIM and Indigenous knowledge to advance planetary health and individual health and well-being across the life course. The Gujarat Declaration Report can be obtained here.

New Rural Initiative Focuses On Age-Friendly Care 

The National Rural Health Association (NRHA) released an an article in Rural Horizons entitled, “New NRHA Initiative Focuses on Age-Friendly Care.” This initiative will help providers offer comprehensive age-friendly care to one in five older adults living in rural areas. These individuals face unique concerns not shared by their urban counterparts. Issues such as traveling farther distances, fewer community spaces, hospital closures, and health care provider shortages have left rural older adults at higher risk for worsening health outcomes. The article can be obtained here.

Imagining The Future Of Postsecondary Education 

Postsecondary education is in a unique moment ripe for reinvention. Members of young age groups are reexamining the value of a college degree as enrollment declines, survey data show Americans have less faith in a four-year degree, and concerns about college debt are widespread. Employers are hungry for talent, especially since the “Great Resignation,” when large numbers of workers quit their jobs following the onset of the COVID-19 pandemic. This environment has created new leverage for workers as support for unions and demands for better pay and working conditions have increased and some employers have reexamined degree requirements. The Urban Institute hosted a two-day workshop in early June 2023 to reimagine the future of postsecondary education so everyone can access a high-quality and affordable education that prepares them for good jobs. Workshop participants included representatives from education, government, research, philanthropy, and business. Together they worked to generate ideas for imagining a more equitable future through postsecondary education, including how to support learners at all points on their education journey through two-generation strategies, robust navigation, effective use of technology, development of a skills infrastructure, and cross-cutting investments to close racial wealth gaps. A workshop report contains the questions that were considered and five interrelated ideas that emerged. The document can be obtained here.

DEVELOPMENTS IN HIGHER EDUCATION

The Biden Administration on August 22, 2023 announced that it has fully launched its updated income-driven repayment application tool on StudentAid.gov, making it possible for student loan borrowers to  enroll in the Saving on A Valuable Education (SAVE) plan. This initiative is part of the Administration’s broader efforts to make college more affordable and to support students and borrowers. The Administration already has approved the cancellation of more than $116 billion in student loan debt for 3.4 million borrowers. The new SAVE plan is expected to provide relief of millions of borrowers money on their monthly payments. 

Additionally, the U.S. Department of Education is announcing a nationwide outreach campaign called “SAVE on Student Debt” in collaboration with leading grass roots organizations. The aim is to leverage strategic partnerships across public, private, and nonprofit sectors to support borrowers by ensuring they take full advantage of the benefits provided by the SAVE plan in addition to the existing resources and debt forgiveness programs available from the Department. 

Under the SAVE plan, a single borrower who makes less than $15 an hour will not have to make any payments. Borrowers earning above that amount would save more than $1,000 a year on their payments compared to other income-driven repayment (IDR) plans. The SAVE plan also ensures that borrowers never see their balance grow due to unpaid interest as long as they keep up with their required payments.

Nominations Solicited For Negotiators To Participate In Public Rulemaking Sessions

The Biden Administration on August 29, 2023 announced the next step in its efforts to open a new pathway to student debt relief by soliciting nominations for negotiators who will participate in public rulemaking negotiation sessions this Fall. The Department of Education seeks nominations from 14 different constituency groups for the Student Loan Relief committee, which will meet for three virtual sessions beginning October 10. Nominations represent the second step in a process known as “negotiated rulemaking,” which is required under the Higher Education Act for any regulations related to the Federal student financial aid programs.  

This process started with a public hearing held by the Department last July 18 and a request for public comments, which solicited more than 24,000 responses. Next, negotiators selected by the Department will meet virtually on October 10-11, November 6-7, and December 11-12 to discuss ideas for regulatory reform. The Department is seeking negotiators representing the following categories, each of which will include a primary and alternate representative: 

· Four spots for current students and student loan borrowers based upon the level of program attended. The Department is particularly interested in a variety of experiences with student loans and postsecondary education, including attending different types of institutions, receiving a Pell Grant, and borrowing a Parent PLUS loan.

· Four spots for different types of institutions of higher education, including Historically Black Colleges and Universities and minority serving institutions.

· Two spots for State officials and Attorneys General.

· Two spots for civil rights organizations and legal assistance organizations.

· One spot for a U.S. military service member or veteran.

· One spot for a representative from the Federal Family Education Loan program. 

The Department will publish proposed rules for the public to comment on in the months following the conclusion of negotiations. Nominations can be sent to negregnominations@ed.gov and must include clear information about nominees. Nominations must be received by September 14, 2023. Additional details on requirements for nominees can be obtained here.

CAPITOL HILL ACTIVITIES

Now that the August recess period for members of congress has ended, September is expected to be characterized by strenuous efforts in both chambers to produce 12 appropriation bills for the next fiscal year that begins on October 1, 2023. Although no legislation has been passed yet in the Senate, the Appropriations Committee was able to complete work on all 12 annual spending bills, where they received bipartisan support. Over in the House, the Military Spending-Veterans Affairs bill passed, but it is expected that progress on the other 11 appropriation bills will be significantly more challenging to achieve. An expectation is that agreement may be reached by the two chambers to have a continuing resolution go into effect that will allow funding to continue until the end of this calendar year at FY 2023 spending levels. 

On a separate related note, the Federal Pell Grant program, authorized by Title IV of the Higher Education Act (HEA), is the single largest source of federal grant aid supporting postsecondary education students. Congress and stakeholders in the higher education and workforce training communities for several years have promoted the possibility of expanding these grants to students enrolled in short-term programs that do not meet the minimum durational requirements in current law. A possible expansion would be intended to provide prospective students with more educational and career options and employers with more skilled applicants. Concerns about a possible expansion generally are related to historical fraud perpetrated by providers of short-term programs and inconsistent employment returns for short-term offerings.  

According to a report issued on August 24 of this year by the Congressional Research Service, generally, undergraduate degree programs and certificate programs of at least 600 clock hours of instruction (or the equivalent) offered over a minimum of at least 15 weeks are eligible. Title IV-participating institutions of higher education must be authorized to operate a postsecondary educational program by the state in which they are located, approved by an accrediting agency recognized by the U.S. Department of Education, and certified by the Department. As of August 2023, three major bills have been introduced in the 118th Congress to expand Pell Grants to short-term programs: 

· Promoting Employment and Lifelong Learning Act (PELL Act; H.R. 496).

· Jobs to Compete Act (H.R. 1655).

· Jumpstart Our Businesses by Supporting Students Act (JOBS Act; S. 161) and its companion, the JOBS Act of 2023 (H.R. 793).  

The bills share several provisions. Short-term programs would be defined as educational offerings providing 150-599 clock hours of instruction offered over 8-14 weeks. The programs would have to be in in-demand industries. Student eligibility would be expanded to otherwise Pell-eligible students who have received a bachelor’s degree, but not a postbaccalaureate degree.

U.S. LIFE EXPECTANCY GAP WIDENS

Now that competition for the next U.S. presidential election cycle has begun heating up, it is common to hear candidates boast that this nation is the greatest on earth. That claim often is perceived as being true in the aggregate, but there also is some value in taking into account certain qualifiers, such as life expectancy trends. The September 2023 issue of the American Journal of Public Health contains several items regarding this particular topic. 

One point of view is that the United States suffers from a health disadvantage. The U.S. population experiences poorer health than populations in other countries and the disadvantage has grown over time. A component of this phenomenon is the U.S. life expectancy disadvantage. Survival in the developed world has increased over the past century, but growth in this country’s life expectancy has not kept pace with that of other industrialized countries. Moreover, the gap with other nations widened dramatically after 2010, when life expectancy plateaued here, but continued increasing elsewhere. 

A recent demonstration of the U.S. health disadvantage occurred during the COVID-19 pandemic, when the United States experienced more deaths from this disease than any other country and had among the highest per capita death rates. U.S. life expectancy decreased by 2.1 years between 2019 and 2021, the largest decline in a century. Other high-income countries experienced smaller decreases in life expectancy during the pandemic, widening the gap to historic levels. The U.S. life expectancy disadvantage began decades ago, but exactly when remains unclear. Studies typically date the onset to the 1980s or 1990s, raising intriguing research questions about events in history that might explain this timing.  

Researchers usually measure the U.S. life expectancy gap in reference to “peer countries,” typically selecting high-income—and largely Western European or Anglo-Saxon—countries as the comparison group. The implicit assumption is that less affluent or developing countries are unlikely to outperform the United States and cannot serve as a benchmark for documenting a U.S. disadvantage. The validity of either assumption—that only high-income countries surpassed the United States and that the phenomenon began in the 1980s to 1990s—is unclear. 

A 2013 National Research Council report explored five domains that might explain the U.S. health disadvantage—health systems, individual behaviors, socioeconomic factors, the environment, and policies and social values—and with each domain found distinctive U.S. characteristics that might contribute to poorer health. Potential contributors included not only downstream, proximal factors, such as obesity, substance abuse, and deficiencies in the U.S. health care system, but also upstream, macrostructural factors, such as U.S. policies. For example, countries with better health outcomes typically offer more generous social welfare and income support programs and enforce stronger regulations to protect public health and safety. Going forward, a prudent first step could be to examine policies that have enabled other countries to outperform the United States for decades.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

National Estimates Of Gender-Affirming Surgery In The U.S.

Trends in inpatient and outpatient gender-affirming surgery (GAS) procedures in the U.S. and in the types of GAS performed across age groups are of interest. As reported on August 23, 2023 in JAMA Network Open, a total of 48,019 patients who underwent GAS were identified, including 25,099 (52.3%) who were aged 19 to 30 years. The most common procedures involved the breast and chest, which occurred in 27,187 patients (56.6%), followed by genital reconstruction (16,872 [35.1%]) and other facial and cosmetic procedures (6,669 [13.9%]). The absolute number of GAS procedures rose from 4,552 in 2016 to a peak of 13,011 in 2019 and then declined slightly to 12,818 in 2020. Overall, 25,099 patients (52.3%) were aged 19 to 30 years, 10,476 (21.8%) were aged 31 to 40, and 3,678 (7.7%) were aged 12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients. 

Nonfatal And Fatal Falls Among Adults Aged ≥65 Years—United States, 2020–2021

Unintentional falls in the U.S. are the leading cause of injury and injury death among adults aged ≥65 years (older adults). Patterns of nonfatal and fatal falls differ by sex and state. According to the September 1, 2023 issue of Morbidity And Mortality Weekly Report, data from the 2020 Behavioral Risk Factor Surveillance System and 2021 National Vital Statistics System were used to ascertain the percentage of older adults who reported falling during the previous year and unintentional fall-related death rates among older adults. In 2020, 14 million (27.6%) older adults reported falling during the previous year. The percentage of women who reported falling (28.9%) was higher than that among men (26.1%). The percentage of older adults who reported falling ranged from 19.9% (Illinois) to 38.0% (Alaska). In 2021, 38,742 (78.0 per 100,000 population) older adults died as the result of unintentional falls. The fall–related death rate ranged from 30.7 per 100,000 population in Alabama to 176.5 in Wisconsin.  

HEALTH TECHNOLOGY CORNER 

Exercise Test Predicts Both Noncardiovascular And Cardiovascular Death

The treadmill exercise test with electrocardiogram (ECG) typically focuses on diagnosing coronary artery disease. A study from the Mayo Clinic described in the September 2023 issue of the journal Mayo Clinic Proceedings finds that exercise test abnormalities, such as low functional aerobic capacity, predicted non-cardiovascular causes of death such as cancer in addition to cardiovascular-related deaths. The investigation  looked at 13,382 patients who had no baseline cardiovascular issues or other serious diseases and who had completed exercise tests at the Mayo Clinic between 1993 and 2010, then were followed closely for a median period of 12.7 years. The principal new finding is that noncardiovascular (CV) deaths predominate in a primary prevention cohort in absence of significant baseline CV disease. The findings suggest that clinicians should focus not only on ECG results, but on data in the exercise test results, such as low functional aerobic capacity, low chronotropic index, and abnormal heart rate recovery. 

Menopause—Biology, Consequences, Supportive Care, And Therapeutic Options

A review published on September 6, 2023 in the journal Cell summarizes the biology and consequences of menopause, the role of supportive care, and the menopause-specific therapeutic options available to women. Optimizing health at menopause is the gateway to healthy aging for women. Although not all women will experience bothersome menopause-related symptoms, the silent effects of the menopause transition may be substantial, such as bone loss increasing future fragility fracture risk and adverse effects on blood lipids and cardiometabolic disease risk. Thus, all women should have access to a general health assessment at the time of menopause transition to maximize their physical well-being, including their cardiometabolic and musculoskeletal health, and their psychological and sexual well-being. Women with bothersome menopausal symptoms should be counseled on treatment options and offered evidence-based therapies, such as menopausal hormone therapy (MHT).

THE ROLE OF SOCIAL DETERMINANTS OF HEALTH

As discussed in the July 4, 2023 issue of the Journal of the American Heart Association, cardiovascular disease (CVD) is the leading cause of mortality worldwide. Addressing social determinants of health (SDoH) may be the next forefront of reducing the enormous burden of CVD. SDoH can be defined as any social, economic, or environmental factor that influences a health outcome. An umbrella review sought to give a comprehensive overview of the role of SDoH in CVD. Four themes (economic circumstances, social/community context, early childhood development, and neighborhood/built environment) and health literacy in the health/health care theme were considered. Despite the quality of the included reviews being low or critically low, there was consistent evidence that factors relating to economic circumstances and early childhood development themes were associated with an increased risk of CVD and CVD mortality. Factors in the social/community context and neighborhood/built environment themes, such as social isolation, fewer social roles, loneliness, discrimination, ethnicity, neighborhood socioeconomic status, violence, and environmental attributes had a role in CVD.  

Apart from clinical interventions, there is a need to strengthen nonmedical interventions that address multiple factors simultaneously. A possible way of doing so addressed in the June 2023 issue of the journal The Milbank Quarterly is to expand the cadre of effective SDoH mitigation strategies. A practical, heuristic framework for policy makers, practitioners, and researchers is needed that serves as a roadmap for conceptualizing and targeting the key mechanisms of SDoH influence. A synthesis of the extant SDoH research into a heuristic framework addresses a scarcity of peer-reviewed organizing frameworks of SDoH mechanisms designed to inform practice. Development of such a framework represents a practical tool to facilitate the translation of scholarly SDoH work into evidence-based and targeted policy and programming. Tools designed to close the research-to-practice translation gap for effective SDoH mitigation are sorely needed.  

HEALTH REFORM DEVELOPMENTS

The United States has the largest economy in the world, with the health care sector representing nearly 19% of it. Given the steady growth in older age cohorts and the likelihood that members of those groups will have one or more chronic ailments, the percentage is destined to continue increasing. Clinicians and the services they provide to patients constitute major focal points in the professional literature. Somewhat less visible is an important personnel sub-group that has a significant impact on the development of health policy. As their careers progress, a revolving door aspect is apparent based on an investigation by the University of Southern California Schaeffer Center for Health Policy & Economics and Harvard University reported in the September 2023 issue of the journal Health Affairs. The study is the first to quantify personnel movement between health-care industries and the government agencies that regulate them. Although there are understandable reasons for movement to occur between the public and private sectors, the study notes that such a revolving door could make  government agencies more vulnerable to pro-industry bias.  

Among individuals appointed to the Department of Health and Human Services (HHS) between 2004 and 2020, 15% had been employed in private industry immediately before their appointment. At the end of their tenure, 32% exited to industry, with the greatest net exits occurring from the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services. A revolving door between government and industry may pose a problem for regulatory agencies, such as the Department of Health and Human Services. The exit of government employees to industry may lead to pro-industry bias. Employees considering a departure from government service may be inclined to make decisions favorable to private firms where they are hoping to obtain jobs. It also is possible that government appointees who come from industry may be more sympathetic to industry interests and could create work environments more open to industry contact and influence.

Mental Health Parity And Addiction Equity Act

The Departments of Labor; Health and Human Services; and the Treasury announced an important step in addressing the nation’s mental health crisis by proposing new rules to improve access to care for mental and substance use disorders. Enacted in 2008, the Mental Health Parity and Addiction Equity Act aims to make sure patients seeking mental health and substance use disorder care do not face greater barriers to treatment than those faced by individuals seeking treatment under their insurance plans for other types of care for physical ailments. Generally, the act prohibits private health insurance companies from imposing copayments, prior authorization, and other requirements on mental health or substance use disorder benefits that are more restrictive than those imposed on medical and surgical benefits. Despite the law’s existence, greater barriers are faced when seeking coverage for mental health and substance use disorder care. The proposed rules can be viewed here. Comments on the proposal are due no later than October 2, 2023.  

Public Knowledge About The Social Security Program

An average of almost 67 million Americans per month in 2023 will receive a Social Security payment, totaling about $1.4 trillion paid during the year. Beneficiaries include 49.4 million retired workers and their 2.6 million dependents; 7.5 million disabled workers and their 1.2 million dependents; and 5.8 million survivors. Nearly nine out of ten individuals age 65 and older were receiving a benefit as of June 30, 2023. Among elderly beneficiaries, 37% of men and 42% of women receive 50% or more of their income from Social Security. Among that elderly group, 12% of men and 15% of women rely on Social Security for 90% or more of their income. Regardless of income level, it can be expected that some of it must be used for health care expenses involving insurance premiums, co-payments, and uncovered services. According to a report published on August 1, 2023 in the Social Security Bulletin, people of color tend to have fewer resources than non-Hispanic White people when they reach retirement age. Consequently, Social Security benefits play an even greater role in retirement security for them. Moreover, study results show that people of color have significantly lower levels of Social Security retirement program knowledge than non-Hispanic Whites. Program knowledge disparities persist across age and education levels and are compounded for women of color. Knowledge about the Social Security retirement program plays an important role in retirement security by helping individuals make optimal decisions about saving and the timing of benefit claiming.  

DEVASTATING CLINICAL CONSEQUENCES OF CHILD ABUSE AND NEGLECT

A companion to the aforementioned consideration of social determinants of health is to take into account the especially baneful clinical consequences of child abuse and neglect. It is well established that maltreatment of children under the age of 18 can be devastating. According to the August 2023 issue of the American Journal of Psychiatry, over the past two decades research has begun not only to define the consequences in the context of health and disease, but also to elucidate mechanisms underlying the link between childhood maltreatment and medical, including psychiatric, outcomes. Research has begun to shed light on how this maltreatment mediates disease risk and course. Childhood maltreatment increases risk for developing psychiatric disorders (e.g., mood and anxiety disorders; posttraumatic stress disorder (PTSD); antisocial and borderline personality disorders; and substance use disorders). Child abuse is associated with an earlier age at onset and a more severe clinical course (i.e., greater symptom severity) and poorer treatment response to pharmacotherapy or psychotherapy. Early-life adversity also is associated with increased vulnerability to several major medical disorders, including coronary artery disease and myocardial infarction; cerebrovascular disease and stroke; type 2 diabetes; asthma; and certain forms of cancer.  

It is estimated that one in four children will experience child abuse or neglect at some point in their lifetime, and one in seven children have experienced abuse over the past year. Also, it is widely accepted that statistics on such reports represent a significant underestimate of the prevalence of childhood maltreatment because the majority of abuse and neglect goes unreported. The situation especially is true for certain types of childhood maltreatment (notably emotional abuse and neglect), which may never come to clinical attention, but have serious impacts on health independently of physical abuse and neglect or sexual abuse. Studies converge on and consistently support the finding that childhood maltreatment increases disease vulnerability for mood disorders, as well as a more pernicious disease course. A reduction in the prevalence of childhood maltreatment would have a substantial impact on decreasing disease burden. Investigations suggesting modifiable targets are only just beginning to emerge and point to behavioral and environmental factors that could be focused on for early interventions. 

HEALTH REFORM DEVELOPMENTS

The United States has the largest economy in the world, with the health care sector representing nearly 19% of it. Given the steady growth in older age cohorts and the likelihood that members of those groups will have one or more chronic ailments, the percentage is destined to continue increasing.      Clinicians and the services they provide to patients constitute major focal points in the professional   literature. Somewhat less visible is an important personnel sub-group that has a significant impact on the development of health policy. As their careers progress, a revolving door aspect is apparent based on an investigation by the University of Southern California Schaeffer Center for Health Policy &    Economics and Harvard University reported in the September 2023 issue of the journal Health Affairs. The study is the first to quantify personnel movement between health-care industries and the government agencies that regulate them. Although there are understandable reasons for movement to occur between the public and private sectors, the study notes that such a revolving door could make government agencies more vulnerable to pro-industry bias.  

Among individuals appointed to the Department of Health and Human Services (HHS) between 2004 and 2020, 15% had been employed in private industry immediately before their appointment. At the end of their tenure, 32% exited to industry, with the greatest net exits occurring from the Centers for       Disease Control and Prevention and the Centers for Medicare and Medicaid Services. A revolving door between government and industry may pose a problem for regulatory agencies, such as the Department of Health and Human Services. The exit of government employees to industry may lead to pro-industry bias. Employees considering a departure from government service may be inclined to make decisions favorable to private firms where they are hoping to obtain jobs. It also is possible that government    appointees who come from industry may be more sympathetic to industry interests and could create work environments more open to industry contact and influence.  

Mental Health Parity And Addiction Equity Act

The Departments of Labor; Health and Human Services; and the Treasury announced an important step in addressing the nation’s mental health crisis by proposing new rules to improve access to care for mental and substance use disorders. Enacted in 2008, the Mental Health Parity and Addiction Equity Act aims to make sure patients seeking mental health and substance use disorder care do not face     greater barriers to treatment than those faced by individuals seeking treatment under their insurance plans for other types of care for physical ailments. Generally, the act prohibits private health insurance  companies from imposing copayments, prior authorization, and other requirements on mental health or substance use disorder benefits that are more restrictive than those imposed on medical and surgical benefits. Despite the law’s existence, greater barriers are faced when seeking coverage for mental health and substance use disorder care. The proposed rules can be viewed at https://www.govinfo.gov/content/pkg/FR-2023-08-03/pdf/2023-15945.pdf. Comments on the proposal are due no later than October 2, 2023.  

Public Knowledge About The Social Security Program

An average of almost 67 million Americans per month in 2023 will receive a Social Security payment, totaling about $1.4 trillion paid during the year. Beneficiaries include 49.4 million retired workers and their 2.6 million dependents; 7.5 million disabled workers and their 1.2 million dependents; and 5.8 million survivors. Nearly nine out of ten individuals age 65 and older were receiving a benefit as of June 30, 2023. Among elderly beneficiaries, 37% of men and 42% of women receive 50% or more of their income from Social Security. Among that elderly group, 12% of men and 15% of women rely on Social Security for 90% or more of their income. Regardless of income level, it can be expected that some of it must be used for health care expenses involving insurance premiums, co-payments, and uncovered services. According to a report published on August 1, 2023 in the Social Security Bulletin, people of color tend to have fewer resources than non-Hispanic White people when they reach retirement age. Consequently, Social Security benefits play an even greater role in retirement security for them. Moreover, study results show that people of color have significantly lower levels of Social Security retirement program knowledge than non-Hispanic Whites. Program knowledge disparities   persist across age and education levels and are compounded for women of color. Knowledge about the Social Security retirement program plays an important role in retirement security by helping individuals make optimal decisions about saving and the timing of benefit claiming.