DEVELOPMENTS IN HIGHER EDUCATION

The Biden-Harris Administration announced that it will hold an additional negotiated rulemaking      session on February 22 and 23 focused on the issue of providing relief for borrowers experiencing hardship. The session is a continuation of work that began last summer when the Administration announced it would pursue a new regulatory process to deliver student debt relief to as many borrowers as possible. These efforts build on the Administration’s approval of more than $136.6 billion in targeted relief for over 3.7 million Americans through various actions. The session will focus exclusively on issues related to hardship, including regulatory text provided at least a week in advance for review by the negotiators and the public. Sessions will be held virtually from 10 AM to 4 PM Eastern Time. There also will be one hour of public comment from 3 PM to 4 PM at the end of the first day.   

Separately, the U.S. Department of Education is continuing its work on draft rules covering other issues discussed at the third session, for publication later this year. This effort includes relief for borrowers whose balances exceed what they originally borrowed, who first entered repayment long ago, who are eligible for relief but have not applied for it, or who attended programs or institutions that failed to provide sufficient financial value. Those issues will not be discussed at this session because the Department already has sought consensus on that regulatory text. 

College Cost Reduction Act

The College Cost Reduction Act (H.R. 6951) was introduced on January 11, 2024 by the House Committee on Education and the Workforce. An impetus for seeking a legislative remedy is that student loan debt is too high, completion rates are too low, and far too many students are left worse off after paying for postsecondary education than if they had never enrolled in the first place. A belief is that for too long, policymakers have relied on patchwork “solutions” that exacerbate these problems without addressing their root cause; which is the inflated cost of obtaining a college degree. The 223-page bill is aimed at responding to challenges, such as rising student loan debt levels, affecting students in postsecondary education. Major sections of the bill involve: Accountability and Student Success; Transparency; and Access and Affordability.  

H.R. 6951 was passed by the committee on a party-line vote on January 31. The next step is for the bill    to move to the House floor for a vote, but no date has been set for doing so. An analysis by the American Council on Education indicates that although there will not be a comprehensive reauthorization of the Higher Education Act this session of Congress, the proposed legislation operates as a blueprint to solutions proposed by Republican members on the committee.  

Student Debt Relief

The Administration announced on January 19 the approval of $4.9 billion in additional student loan debt relief for 73,600 borrowers. These discharges are the result of fixes made by the Administration to income-driven repayment (IDR) forgiveness and Public Service Loan Forgiveness (PSLF). Total loan forgiveness approved amounts to $136.6 billion for more than 3.7 million Americans. Debt relief is broken down into the following categories: 

· $1.7 billion for 29,700 borrowers through administrative adjustments to IDR payment counts that have brought borrowers closer to forgiveness and address longstanding concerns with the misuse of       forbearance by loan servicers. Including the present announcement, the Administration has approved   $45.7 billion in IDR relief for 930,500 borrowers. 

· $3.2 billion for 43,900 borrowers through PSLF, which includes borrowers who have benefitted from the limited PSLF waiver as well as regulatory improvements made to the program. Total relief through PSLF is $56.7 billion for 793,400 borrowers since October 2021.  

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Mortality in Adults Age 65 and Older: United States, 2000–2019 

National Vital Statistics Reports on December 15, 2023 presented data on trends in mortality before the COVID-19 pandemic for adults age 65 and older. Death rates are presented by age group; sex; race and Hispanic origin; urban–rural status; and leading causes of death. From 2000 through 2019, age-adjusted death rates for adults age 65 and older decreased from 5,169.0 deaths per 100,000 U.S. standard population to 4,073.8, with a slower rate of decline from 2009 onward compared with earlier years. Among women, declines occurred in all age groups (65–74, 75–84, and 85 and older). Among men, declines occurred for those ages 75–84 and 85 and older. Overall, for men ages 65–74, death rates were stable from 2012 through 2019, however, death rates for Black non-Hispanic men ages 65–74 increased by 0.3% annually. Age-adjusted death rates were higher in rural areas than urban areas and declined more slowly in rural areas.

Black Mother's Experiences, Communication, And Support In The Neonatal Intensive Care Unit

A study described in the January 2024 issue of the journal Ethnicity & Health involved an examination of  Black mothers' perceived provider communication, support needs, and overall experiences in the neonatal intensive care unit (NICU). Among the mothers participating in the study, most were married; had a cesarean birth; had a previous pregnancy complication (e.g., diabetes, hypertension); had attained a graduate degree or more; earned an annual household income of $75,000 or more; and were between 35–44 years of age. The study reinforces the need for racially congruent interventions and policy reformations to protect Black birthing women regardless of socioeconomic factors and social class using life course, holistic approaches, and intersectionality mindset. Importantly, this study calls for culturally sensitive research to capture the nuances associated with the multiplicity of experiences of Black people. 

HEALTH TECHNOLOGY CORNER 

Inhalable Sensors To Enable Early Lung Cancer Detection

Disproportionately high mortality is observed in lung cancer cases in low- and middle-income countries and correlates with late-stage disease detection, illustrating inequity in early diagnosis in resource-poor settings, one of the chief challenges in addressing cancer health disparities. A strategy to address such inequity is to lower the technological threshold for a patient’s access to screening programs and early detection.  Using a new technology developed at the Massachusetts Institute of Technology, diagnosing lung cancer could become as easy as inhaling nanoparticle sensors and then taking a urine test that reveals whether a tumor is present, according to research described in an article published in the journal Science Advances on January 5, 2024. The new diagnostic is based on nanosensors that can be delivered by an inhaler or a nebulizer. If the sensors encounter cancer-linked proteins in the lungs, they produce a signal that accumulates in the urine, where it can be detected with a simple paper test strip.

Underground Anti-Aging Secrets From Burrowing Rodents

Naked mole rats (Heterocephalus glaber) do not look beautiful, but they age gracefully. They survive past 30 years old, whereas laboratory mice rarely have a third birthday. Unlike mice and humans, age does not curse naked mole rats with cancer, dementia or heart disease. A few factors that keep them young are that their DNA repairs itself well when damaged and their cells have many antioxidants. but their most interesting anti-aging strategy may be outside their cells altogether. According to an article in the December 2023 issue of the Journal of Experimental Biology (No. 23), most cells live in a blanket of molecules and minerals called an “extracellular matrix.” Naked mole rats produce a heavier and larger version of the molecule hyaluronan, which is the backbone of the extracellular matrix. This extra padding protects cells from inflammation and early death. Researchers genetically modified mice to produce this naked mole rat version of hyaluronan throughout their skin, muscles, and internal organs.  

DEVELOPMENTS IN HIGHER EDUCATION

The U.S. Department of Education has been highly active in recent weeks. Additional steps are being taken on rulemaking to strengthen institutional quality and program integrity to help ensure students are well served by the institutions of higher education they attend and that Federal Student Aid programs work in their best interest. The Department on January 2, 2024 began the new year by releasing six issue papers across a range of categories to further these goals, which will be discussed during the first meeting of the Institutional Quality and Program Integrity Committee, meeting on January 8-11. The issue papers include proposals to ensure that accrediting agencies and state authorizing agencies are appropriately holding institutions accountable for providing high-quality educational opportunities. They also include proposals to create more consumer-friendly policies to ensure students have access to their aid to help cover college costs and receive fair treatment across aid programs.  

Topics on the agenda for the first meeting of the Institutional Quality and Program Integrity Committee include: 

· Cash Management rules which govern the procedures institutions must follow for issuing and managing Title IV aid.

· Return of Title IV Funds rules which outline the process institutions must conduct when a student ceases attendance during a payment period or period of enrollment.

· Accreditation rules which guide the process the Department uses to recognize accrediting agencies, the independent private non-profit and state entities responsible for overseeing the quality of education provided by institutions and programs.

· State Authorization rules which govern the requirements for an institution to be considered legally authorized by the state in which it operates, a requirement for Title IV eligibility.

· Distance Education rules to enable the Department to obtain better data and compare outcomes for students enrolled online and to better protect students in the event of college closures.

· TRIO rules which govern eligibility of the Federal TRIO programs that would expand participation to more students from disadvantaged backgrounds. 

The committee will be comprised of non-federal negotiators from 15 constituency groups. A subcommittee focused on TRIO programs will meet on January 12. The Department will obtain views from the non-federal negotiators and also hear from members of the public at the end of each day. The process is designed to continue to refine and develop proposals for consideration. The committee will meet again in February and March, while the subcommittee will meet again in February. 

Student Loan Debt Relief

The Biden Administration announced on December 6  the approval of an additional $4.8 billion in student loan debt relief for 80,300 borrowers. These discharges stem from fixes made by the U.S. Department of Education to income-driven repayment (IDR) forgiveness and Public Service Loan Forgiveness (PSLF). The announcement brings the total approved debt cancellation by the Administration to nearly $132 billion for more than 3.6 million Americans. 

Education Grants For Students In Rural Communities

The Administration on December 22 announced $44.5 million in grants to 22 institutions of higher education to improve rates of postsecondary education enrollment, persistence, and completion among students in rural communities. The grant program promotes the development of high-quality career pathways aligned to high-skill, high-wage, and in-demand industry sectors and occupations in the region.

HEALTH REFORM DEVELOPMENTS

The Patient Protection and Affordable Care Act (ACA) will celebrate it 14th year of existence this coming March. Long-standing goals associated with health reform legislation over the decades were to increase the proportion of the U.S. population that benefits from having health insurance coverage and lowering the spiral of ever rising health care costs. Latest information from the Centers for Medicare & Medicaid Services (CMS) serves as a scorecard for measuring such achievements, According to that source, ACA Marketplace enrollment continues at a record-breaking pace. As of December 15, 2023, for HealthCare.gov states and December 9, 2023, for State-based Marketplaces, preliminary data project that more than 19 million consumers will enroll in 2024 coverage through the ACA Market-places, which exceeds by over seven million the number when President Biden took office. On December 15 of last year, the deadline for coverage starting January 1, 2024, more than 745,000 individuals selected a Marketplace plan through HealthCare.gov, the largest single day in history.  

As reported in an article in the journal Health Affairs, health care spending in the U.S. grew 4.1% to reach $4.5 trillion in 2022, which still was a faster rate of growth than the increase of 3.2% in 2021. The insured share of the population reached a historic high of 92.0% in 2022 as enrollment in private health insurance increased at a faster rate relative to 2021 and Medicaid enrollment continued to experience strong growth. The share of the economy accounted for by the health sector was 17.3% in 2022, which was down from a peak of 19.5% in 2020, but was more consistent with the average share of 17.5% during 2016–19.

Large Language Models And Digital Health

Looking ahead rather than retrospectively, as discussed in an editorial in the January 2024 issue of the journal The Lancet Digital Health, it took only five days for ChatGPT's user base to reach one million following the launch of GPT-3.5 in November 2022. Now, it has around 180 million users. The enormous global interest in large language models (LLMs), the models that power ChatGPT, is fueled by their massive potential. LLMs have been used to make varied advancements across multiple fields in 2023, but how will they affect patients’ health in 2024? 

The Fall 2023 issue of the Institute Letter from the Institute for Advanced Study at Princeton University furnishes a larger context for contemplating future advancements in technology. Decades ago, J. Robert Oppenheimer, Albert Einstein, and John von Neumann, along with other Institute faculty channeled much of their effort toward what AI researchers today call the “alignment” problem: how to make sure our discoveries serve us instead of destroying us. Oppenheimer’s conviction was that “the safety” of a nation or the world “cannot lie wholly or even primarily in its scientific or technical prowess.” If humanity wants to survive technology, he believed it needs to pay attention not only to technology but also to ethics, religions, values, forms of political and social organization, and even feelings and emotions. He set out to make the Institute a place for thinking about humanistic subjects like Russian culture, medieval history, or ancient philosophy, as well as about mathematics and the theory of the atom. He believed we need to be reminded that no alignment of technology with humanity can be achieved through technology alone. Technological challenges are growing, but the cultural abyss separating STEM from the arts, humanities, and social sciences has only grown wider.

Federal Budget Deficits And Government Spending Controversies

Each year, the federal budget deficit grows. Efforts to deal with the problem that entail reducing expenditures on government programs or increasing the level of taxation continue to be unpopular with large portions of the electorate. Characteristics of this perennial problem are reflected in the difficulty Congress faces each year in passing appropriation bills, which is described in another article in this issue of the ASAHP newsletter. 

Many proposed spending cuts each year involve the health sector of the U.S. If enacted, the National Institutes of Health and the Centers for Disease Control and Prevention would be among the entities that would find it more challenging to carry out core functions aimed at enhancing individual and community health status. Other agencies that would be affected severely are the Health Resources and Services Administration, which focuses on the health workforce, and the Agency for Healthcare  Research and Quality, a perennial target for total elimination. 

APPROPRIATIONS ACTION NEEDED

The new year of 2024 arrived with much work still remaining to produce necessary spending legislation for President Biden to sign into law. In past years, almost all major focus was on bills involving domestic spending. The present situation is different, however, owing to the war between Ukraine and Russia. The U.S. already has provided billions of dollars for Ukraine, but more  support is required. Although there is bipartisan agreement on the necessity of continuing to help the Ukrainians in their struggle, many Republicans in both legislative chambers want to link such funding with increased efforts to secure the southern border of the U.S.  

The clock is ticking while previously established deadlines soon must be met in some constructive fashion. Otherwise, the unwanted threat of a federal government shutdown looms ever larger with each passing day. Lawmakers returned to Capitol Hill on the week beginning January 8. The first deadline arrives on the 19th of that month. If it is not met, a partial shutdown takes effect. Unless significant progress is made, a total cessation of government activity will occur on February 2 when a continuing resolution (CR) expires. A chief aim is to develop a broad spending package beforehand, but attaining that objective depends on reaching an agreement on overall funding levels. Regrettably, that stage has not been reached yet.  

As an example of the many hurdles that must be overcome to produce 12 spending bills, a chief component is the measure for Labor-HHS (H.R. 5894, Departments of Labor, Health and Human Services, and Education, and Related Agencies), which has a significant impact on both the health care and higher education domains. Not only does the bill allow for 146 amendments to be considered, the legislation is in the context of highly controversial topics, such as abortion and gun control. Typically, the amount of funding sought for this bill differs widely between the two chambers.  

In the event Congress is unable to reach agreement on funding for the fiscal year that began last October 1, House Speaker Mike Johnson (R-LA) has proposed extending the current stopgap spending bill through the end of this fiscal year on September 30. Senator Patty Murray (D-WA), who heads the Appropriations Committee, responded to that proposal on December 18 by releasing a committee fact sheet detailing the devastating harm that would be caused by a recommendation to pass a date-change, full-year CR if Congress is unable to pass funding bills by the fast-approaching deadlines. Her fact sheet outlines what the proposal would mean for the nation and provides detailed implications for defense and non-defense programs across all 12 appropriations bills.  

Speaking on the Senate floor, she indicated that a full-year continuing resolution (CR) as proposed would be unprecedented and reckless because it would lock in outdated spending plans and detrimental across-the-board cuts while locking out any kind of thoughtful decision-making process for the nation’s future.

She stated that a full-year CR would be unprecedented and harmful for families in every zip code, for U.S. national security, and for this country’s future.

CLOSING THE RING OF UNCERTAINTY

Apart from key factors, such as attempts to reduce poverty and bring about positive lifestyle changes, enhancement of individual and community health status also depends to a significant extent on the availability of affordable and high quality health care services. Periodically, this newsletter serves as a vehicle for identifying instances where more improvements are necessary. Depending on which health professions are involved and types of diseases, deficiencies in nomenclature can play an important role in affecting health care quality.

An article by Peterson et al in the December 2023 issue of the journal JAMA Neurology discusses how nomenclature in the field of neurodegenerative diseases presents a challenging problem. The authors note that inconsistent use of terms such as Alzheimer disease and dementia has compromised progress in clinical care, research, and development of therapeutics. Dementia-associated stigma further contributes to inconsistent and imprecise language. The result is a lack of clarity that produces confusion with patients and the general public, and presents communication challenges among researchers.  

Thus, the Advisory Council on Research, Care, and Services of the National Plan to Address Alzheimer’s Disease authorized a committee to make recommendations for improvement. This Dementia Nomenclature Initiative established a framework to guide communication about cognitive impairment among older adults. Wider testing and refinement of the framework subsequently will improve the information used in communicating about cognitive impairment and the way in which the information is used in clinical, research, and public settings. 

Unfortunately, disagreements can occur that impair an ability to arrive at easy and timely remedies in areas that are controversial. In an article by Nyame and colleagues in the November 2023 issue of the Journal of the National Cancer Institute on the topic of putting patients first to redefine prostate cancer classifications, the debate over removing the cancer designation for low-grade prostate cancer has taken center-stage recently. Proponents of a name change for grade group 1 (GG1) prostate cancer cite 1) extremely low rates of progression, metastasis, and death; 2) patient anxiety related to having a cancer diagnosis; and 3) the harms of overdiagnosis and overtreatment as reasons to remove the cancer label from GG1 prostate cancer.  

Opponents of this name change point to the fact that 1) although less common, patients with GG1 cancers can demonstrate extraprostatic extension, metastases, and recurrence following treatment; 2) GG1 cancers meet the histologic definition of a cancer (i,e,, loss of the basement membrane); and 3) the name change may lead to adverse oncologic outcomes if any of the 25% to 50% of patients with prostate cancer reclassification are lost to follow-up because of removal of the cancer label. A related concern is that a cancer label induces anxiety and fear of cancer progression that may be impervious to even the best clinician’s counseling.

NEIGHBORHOOD EFFECTS ON POPULATION HEALTH AND INEQUITIES

Interest in research on the relationship between place and health has expanded dramatically in recent decades, with a focus on the geographic unit of neighborhoods, or “geographical places that can have social and cultural meaning … and are subdivisions of large places.” This trend has been driven by the recognition that individual-level factors alone are insufficient to understand population health, interest in structural determinants of health, and capability around linkages between neighborhood and health data. Existing literature has documented how characteristics of the neighborhood environment operate through multiple pathways to shape population health. As evidence of the relationship between place and health mounts, more epidemiologists and clinical science researchers are becoming interested in incorporating place-based measures and analyses into their examination of population health and health inequities. According to an article in the October 2023 issue of the American Journal of Epidemiology, given the extensive literature on place and health, it can be challenging for researchers new to this area to develop neighborhood-effects research questions and apply the appropriate measures and methods. 

A paper in the journal provides a road map for guiding health researchers through the conceptual and methodological stages of incorporating various dimensions of place into their quantitative health research. Synthesizing across reviews, commentaries, and empirical investigations, the road map consists of four broad stages for considering place and health: 1) why?: articulating the motivation for assessing place and health and grounding the motivation in theory; 2) what?: identifying the relevant place-based characteristics and specifying their link to health to build a conceptual framework; 3) how?: determining how to operationalize the conceptual framework by defining, measuring, and assessing place-based characteristics and quantifying their effect on health; and 4) now what?: discussing the implications of neighborhood research findings for future research, policy, and practice. The road map supports efforts to develop conceptually and analytically rigorous neighborhood research projects. Exciting possibilities exist for future work.

UNDERSTANDING DIAGNOSTIC CONVERSATIONS

Diagnostic excellence refers to an optimal process to obtain an accurate explanation of a patient's condition. This process usually begins when a patient experiences a symptom or a problem and seeks care, followed by iterative information gathering, integration, and interpretation to arrive at a working diagnosis. A manuscript published in the November 2023 issue of the journal Patient Education and Counseling points out that this diagnostic process includes collaboration and co-creation of the working diagnosis and diagnostic plan by patients, caregivers and clinicians. Evidence supports the importance of engaging patients and their caregivers to improve clinical outcomes and the safety of the diagnostic process. Yet, most improvement has focused on the role of patients as a source of information and assuring adequate delivery of diagnostic information to patients, more than including patients in the process through active collaboration. Diagnostic errors are defined as a "failure to establish an accurate and timely explanation of the patient's health problem or communicate that explanation to the patient.” This definition highlights diagnosis as a process. It emphasizes the importance of adequate communication between clinicians and patients.  

Nonetheless, in a systematic review of 16 studies evaluating diagnostic errors, only four investigations evaluated the "communication" component of the diagnostic error definition. Communication between patients and clinicians is central in diagnostic conversations as it allows a) patients’ presentation of their symptoms that guide subsequent diagnostic steps, b) negotiation of the significance of the patients’ symptoms through conversation, and c) introducing and resolving diagnostic uncertainty. Overall studies highlighted different activities that patients and clinicians complete during the diagnostic visit that potentially could serve as barriers (e.g., not understanding the significance of the patients’ symptoms) or facilitators (e.g., discussing diagnostic uncertainty) to diagnostic excellence. Lack of agreement on the importance of a problem between patient and clinicians can have negative consequences such as loss of trust, non-attendance to follow up visits or non-completion of diagnostic tests. Patient and clinicians also should cooperate when developing the diagnostic plan and consider not only the perceive benefit of a test, but the patient effort required to implement the diagnostic plan. 

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Mortality in Adults Age 65 and Older: United States, 2000–2019 

National Vital Statistics Reports on December 15, 2023 presented data on trends in mortality before the COVID-19 pandemic for adults age 65 and older. Death rates are presented by age group; sex; race and Hispanic origin; urban–rural status; and leading causes of death. From 2000 through 2019, age-adjusted death rates for adults age 65 and older decreased from 5,169.0 deaths per 100,000 U.S. standard population to 4,073.8, with a slower rate of decline from 2009 onward compared with earlier years. Among women, declines occurred in all age groups (65–74, 75–84, and 85 and older). Among men, declines occurred for those ages 75–84 and 85 and older. Overall, for men ages 65–74, death rates were stable from 2012 through 2019, however, death rates for Black non-Hispanic men ages 65–74 increased by 0.3% annually. Age-adjusted death rates were higher in rural areas than urban areas and declined more slowly in rural areas.  

Black Mother's Experiences, Communication, And Support In The Neonatal Intensive Care Unit

A study described in the January 2024 issue of the journal Ethnicity & Health involved an examination of  Black mothers' perceived provider communication, support needs, and overall experiences in the neonatal intensive care unit (NICU). Among the mothers participating in the study, most were married; had a cesarean birth; had a previous pregnancy complication (e.g., diabetes, hypertension); had attained a graduate degree or more; earned an annual household income of $75,000 or more; and were between 35–44 years of age. The study reinforces the need for racially congruent interventions and policy reformations to protect Black birthing women regardless of socioeconomic factors and social class using life course, holistic approaches, and intersectionality mindset. Importantly, this study calls for culturally sensitive research to capture the nuances associated with the multiplicity of experiences of Black people. 

HEALTH TECHNOLOGY CORNER 

Inhalable Sensors To Enable Early Lung Cancer Detection

Disproportionately high mortality is observed in lung cancer cases in low- and middle-income countries and correlates with late-stage disease detection, illustrating inequity in early diagnosis in resource-poor settings, one of the chief challenges in addressing cancer health disparities. A strategy to address such inequity is to lower the technological threshold for a patient’s access to screening programs and early detection.  Using a new technology developed at the Massachusetts Institute of Technology, diagnosing lung cancer could become as easy as inhaling nanoparticle sensors and then taking a urine test that reveals whether a tumor is present, according to research described in an article published in the journal Science Advances on January 5, 2024. The new diagnostic is based on nanosensors that can be delivered by an inhaler or a nebulizer. If the sensors encounter cancer-linked proteins in the lungs, they produce a signal that accumulates in the urine, where it can be detected with a simple paper test strip.  

Underground Anti-Aging Secrets From Burrowing Rodents

Naked mole rats (Heterocephalus glaber) do not look beautiful, but they age gracefully. They survive past 30 years old, whereas laboratory mice rarely have a third birthday. Unlike mice and humans, age does not curse naked mole rats with cancer, dementia or heart disease. A few factors that keep them young are that their DNA repairs itself well when damaged and their cells have many antioxidants. but their most interesting anti-aging strategy may be outside their cells altogether. According to an article in the December 2023 issue of the Journal of Experimental Biology (No. 23), most cells live in a blanket of molecules and minerals called an “extracellular matrix.” Naked mole rats produce a heavier and larger version of the molecule hyaluronan, which is the backbone of the extracellular matrix. This extra padding protects cells from inflammation and early death. Researchers genetically modified mice to produce this naked mole rat version of hyaluronan throughout their skin, muscles, and internal organs.  

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Tobacco Product Use Among U.S. Middle And High School Students, 2023

As reported on November 3, 2023 in Morbidity and Mortality Weekly Reports, tobacco product use during adolescence increases the risk for lifelong nicotine addiction and adverse health consequences. CDC and the Food and Drug Administration analyzed data from the 2023 National Youth Tobacco Survey to assess tobacco product use patterns among U.S. middle school (grades 6–8) and high school (grades 9–12) students. In 2023, 10.0% of middle and high school students (2.80 million) reported current (i.e., past 30-day) use of any tobacco product. Current use of any tobacco product by high school students declined by an estimated 540,000, from 2.51 million in 2022 to 1.97 million in 2023. From 2022 to 2023, current e-cigarette use among high school students declined from 14.1% to 10.0%. Among middle and high school students, e-cigarette products were the most used tobacco product in 2023 (7.7%; 2.13 million), followed by cigarettes (1.6%), cigars (1.6%), nicotine pouches (1.5%), and smokeless tobacco (1.2%). 

Prevalence Of Alzheimer’s Disease Dementia In U.S. States And Counties, 2020

Researchers used cognitive data from the Chicago Health and Aging Project, a population-based study, and combined it with the National Center for Health Statistics 2020 bridged-race population estimates to determine the prevalence of Alzheimer’s Disease dementia in adults ≥65 years in 50 U.S. states and 3,142 counties. As described in the October 2023 issue of the journal Alzheimer’s & Dementia, a higher prevalence of Alzheimer’s Disease (AD) was estimated in the east and southeastern regions of the United States, with the highest in Maryland (12.9%), New York (12.7%), and Mississippi (12.5%). U.S. states with the highest number of individuals with AD were California, Florida, and Texas. Among larger counties, those with the highest prevalence of AD were Miami-Dade County in Florida, Baltimore city in Maryland, and Bronx County in New York. Such estimates could help public health officials develop region-specific strategies for caring for patients with AD. 

HEALTH TECHNOLOGY CORNER 

Digital Health, AI, Ethical Implications, And Threats To Dignity

Bioethics researchers at Dana-Farber Cancer Institute in Boston call on relevant parties, e.g., medical societies, to work together to ensure AI-driven health care preserves patient autonomy and respects human dignity. In an article published on November 3, 2023 in JCO Oncology Practice, the authors note medical professionals and technology developers need to act now to prevent the technology from depersonalizing patient care and eroding relationships between patients and caregivers. The authors focus on three areas in which patients are likely to engage with AI now or in the future. Telehealth may use AI to shorten wait times and collect patient data before and after appointments. Remote monitoring of patients' health may be enhanced by AI systems that analyze information reported by patients themselves or collected by wearable devices. Health coaching can employ AI to provide personalized health advice, education, and psychosocial support. AI poses a variety of ethical challenges, many of which have yet to be  addressed adequately.

GenAI In Higher Education

Students and instructors have gained a new powerful tool in generative AI models. While use of GenAI has expanded significantly across the last six months, the current use by instructors and students is characterized as nascent. Yet, the ultimate impact on teaching and learning in higher education and workforce needs still is unknown. A pulse survey conducted in September 2023 by Tyton Partners reaching more than 1,000 higher education faculty and 1,600 current postsecondary students found that nearly half of students are regular users of GenAI while faculty at only 22% consistently are significantly lagging students in their use of this resource. GenAI writing tools include ChatGPT, Google Bard, Microsoft Bing Chat, or Meta Llama 2. Additionally, 75% of students indicate that they will continue to use GenAI even if their professors or institutions ban the technology. Both faculty and students believe that GenAI tools will be needed to succeed in the workforce. 

DEVELOPMENTS IN HIGHER EDUCATION

The Biden administration continues its efforts to deliver student debt relief to as many borrowers as possible through negotiated rulemaking under the Higher Education Act by releasing draft regulatory text for specific categories of borrowers and outlining next steps to consider relief options for borrowers experiencing hardship. Forgiveness delivered to borrowers through negotiated rulemaking will build on the historic actions the Administration already has taken to provide student debt relief to millions of Americans. Thus far, $127 billion in debt relief for nearly 3.6 million borrowers has been approved in addition to launching the SAVE plan, a student loan repayment mechanism. Draft regulatory text was released that provides debt relief for four groups of borrowers, including those who: 

• Currently have outstanding federal student loan balances that exceed what they originally borrowed.

• Have loans that first entered repayment 25 or more years ago.

• Took out loans to attend career-training programs that created unreasonable debt loads or provided insufficient earnings for graduates, as well as borrowers who attended institutions with unacceptably high student loan default rates.

• The Secretary determines are eligible for forgiveness under repayment plans like income-driven repayment or targeted relief programs like Public Service Loan Forgiveness or closed school loan discharges except they have not applied for such relief. 

A U.S. Department of Education issue paper outlines additional questions and information to guide discussion about a fifth group of borrowers, i.e., those who are experiencing financial hardship that the current student loan system does not address adequately. The paper outlines concepts raised during the first negotiating session on October 10-11, 2023 that require further development and discussion to identify potential regulatory proposals or future policymaking efforts. Questions in the paper include which types of borrowers may be experiencing hardship, whether standards used to make improvements to the bankruptcy process could be applied to student debt relief, and what data would be needed to determine whether a borrower is facing hardship. The second session was held on November 6-7. Session Three is scheduled for December 11-12. 

Modifying The Carnegie Classification Of Higher Education Institutions

The American Council on Education (ACE) and the Carnegie Foundation for the Advancement of Teaching announced a series of changes on November 1, 2023 to modernize the Carnegie Classification of Institutions of Higher Education, the framework used for five decades to classify American colleges and universities. The iteration of the Carnegie Classifications that will be released in early 2025 will revise the Basic Classification, which generally places all U.S. colleges and universities into groups based on the highest degree awarded. The updated classifications will create new, multi-dimensional groupings  that go beyond the single label (such as Master’s Colleges and Universities: Medium Programs) that is now      assigned to every U.S. college and university. The classification categories will be expanded to describe more accurately the richness and multifaceted nature of today’s colleges and universities and additionally capture aspects of institutions’ missions. The precise labels still are under development. 

The 2025 Carnegie Classifications also will make significant changes to how research is recognized, including to the methodology that determines whether an institution is classified as R1. A new threshold  establishes a clear and transparent target for institutions whose mission supports prioritizing research. Additionally, the Carnegie Classifications will identify and recognize research contributions made across the vast network of colleges and universities in the U.S., including at institutions not offering doctoral degrees. A new designation known as “Research Colleges and Universities” will capture research underway at institutions that only serve undergraduate students. Any institution that spends at least $2.5 million on research will be included in this category, provided they are not in the R1 or R2 classifications.

HEALTH REFORM DEVELOPMENTS

The Patient Protection and Affordable Care Act became law in March 2010. When President Obama took office one year earlier, his administration was heralded for its unprecedented technological aptitude. Yet when Healthcare.gov launched in 2013, after three years of work and a cost of more than $300 million, the website crashed. Fewer than 10 individuals were able to enroll on the first day. As noted in an article appearing in the November/December 2023 issue of the journal MIT Technology Review, in the years since then, that particular crash was indicative of massive challenges that the U.S. continues to face when it comes to government use of technology. Reference in the paper is made to Jennifer Pahlka who served as deputy chief technology officer of the White House Office of Science and Technology Policy back then. As she explains in her book “Recoding America: Why Government Is Failing in the Digital Age and How We Can Do Better,” the failed site launch was a reflection of just how big the glaring gap between policy intentions and actual outcomes really is. 

She argued that policy implementation has grown so complex and technology often complicates it even further. Technology can be as much a part of the problem as it is part of the solution. Even when technology is promising, its deployment requires money and talent. Budget realities, bureaucratic red tape, election cycles, and ever-growing legal complexities all pose significant challenges. Implementing technology accurately is no simple task, especially when the public is accustomed to easy-to-use interfaces and information management systems from the likes of Apple, Microsoft, and Google. All these factors contribute to having problems with government technology when it has never been more critical to improve government effectiveness. 

2023 Employer Health Benefits

Employer-sponsored insurance covers almost 153 million nonelderly beneficiaries. KFF conducts an annual survey of private and non-federal public employers with three or more workers. This 25th survey reflects employer-sponsored health benefits in 2023. It was fielded from January to July of 2023. The average annual premium for employer-sponsored health insurance this year is $8,435 for single coverage and $23,968 for family coverage. Over the last five years, the average premium for family coverage has increased by 22% compared to a 27% increase in workers’ wages and 21% inflation. Most covered workers contribute to the cost of the premium for their coverage. On average, covered workers contribute 17% of the premium for single coverage and 29% of the premium for family coverage, similar to the percentages contributed in 2022. The average annual dollar amounts contributed by covered workers in 2023 are $1,401 for single coverage and $6,575 for family coverage, similar to the amounts last year but greater than five years ago.  

Ninety percent of workers with single coverage have a general annual deductible that must be met before most services are paid for by the plan, similar to the percentage last year (88%). The average deductible amount in 2023 for workers with single coverage and a general annual deductible is $1,735, similar to last year. In 2023, among workers with single coverage, 47% of workers at small firms and 25% of workers at large firms have a general annual deductible of $2,000 or more. Over the last five years, the percentage of covered workers with a general annual deductible of $2,000 or more for single coverage has grown from 26% to 31%.

Comprehensive Demographic Profile Of The U.S. Evicted Population

Each year 2.7 million U.S. households receive an eviction filing. A manuscript in the October 10, 2023 issue of the Proceedings of the National Academy of Sciences (PNAS) links millions of eviction court records to Census Bureau data to describe the population of renters facing eviction. Each year, 2.9 million children are affected by an eviction filing, and the typical eviction case filed in America involves one child. Evicted children face increased risk of food insecurity, exposure to environmental hazards, academic challenges, and a range of long-term physical and mental health problems. Despite making up only 18.6% of all renters, Black Americans account for 51.1% of those affected by eviction filings and 43.4% of those evicted. Roughly one in five Black Americans living in a renter household is threatened with eviction annually, while one in ten is evicted.

APPROPRIATIONS QUEST CONTINUES

History indicates that it is highly challenging to enact 12 spending bills by the start of a new fiscal year each October 1. Fiscal Year 2024 is not proving to be an exception. Not only has there been the usual assortment of obstacles to overcome in reaching an agreement between legislators of both political parties in the two chambers, this year included a motion to vacate the chair, which led to the demise of House Speaker Kevin McCarthy (R-CA). That unprecedented event was followed by three weeks of chaos in choosing a successor. Obvious possible choices of leading candidates in the Republican party failed to achieve a sufficient number of votes. Instead, a relatively little known back bencher from Louisiana, Michael Johnson, was selected as the next Speaker. Oddly enough, he will function in the same manner that affected former Speaker McCarthy adversely. A single vote to vacate the chair also would end Speaker Johnson’s occupancy of that position. 

He faces some daunting challenges in efforts to move forward in achieving significant outcomes. Congress was able to reach a last minute agreement at the end of September to produce a continuing resolution (CR) to avoid a government shutdown. That mechanism expires on November 17. What comes next has yet to be determined. One possibility is to have another CR that would last until either mid-January 2024 or mid-April of that year. The latter option is not an attractive choice because Congress faces an effective April 30 deadline to pass spending legislation. The most recent debt ceiling agreement included a provision to subject all discretionary spending to a 1% reduction should a CR still be in place past that date.  

During the period that Republicans endeavored to select a new Speaker, it became evident that additional emergency funding would be needed for the purpose of aiding Israel, Ukraine, and securing the southern U.S. border. Speaker Johnson and his colleagues prefer dealing with each issue separately while President Biden and leading congressional Democrats want spending to be in a single package. Meanwhile, the House of Representatives has passed seven of the 12 annual appropriations while the Senate passed the chamber’s first minibus package containing appropriations for three spending bills. The two chambers are $100 billion apart in their spending aims. Many House Republicans, such as members of the Freedom Caucus are adamant regarding the need to reduce a federal deficit that exceeds $33 trillion and to balance this fiscal year’s budget by reducing expenditures. 

Apart from having another CR and reaching an agreement on the amount of emergency aid to provide, there will need to be a reconciliation of perennial squabbles that involve contentious topics, such as gun violence, abortion, and issues pertaining to gender identity or sexual orientation. Another consideration of major importance is the impending national election in 2024. Whatever votes are taken by individual legislators may influence their success in holding on to the seats they currently occupy. Each political party seeks to be the majority in the House and the Senate, and in controlling the White House.

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.