QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Availability of Mental Telehealth Services in the U.S.

Telehealth availability for mental health care varies significantly across states, according to a new RAND study. The findings were published in the journal JAMA Health Forum on February 2, 2024. Of the 1,221 facilities (87%) accepting new patients, 980 (80%) reported offering telehealth. Of these, 97% (937 facilities) reported availability of counseling services; 77% (726 facilities), medication management; and 69% (626 facilities) diagnostic services. Telehealth availability did not differ by clinical condition. Researchers found there were differences in services offered depending on whether a mental health treatment facility was located in a rural or metropolitan area. The types of services offered, and the types of telehealth modalities available, also varied widely among clinics, with roughly one in four clinics not offering virtual medication management and about one in three not offering virtual diagnostic services. No significant differences occurred based on the callers’ perceived race and ethnicity.

Lack Of Reliable Transportation For Daily Living Among Adults: United States, 2022

Access to transportation may be required for many daily tasks, including going to work and health care visits. Previous research suggests that a lack of transportation, especially among adults who are older, uninsured, and have lower incomes, leads to reduced access to health care, and adverse health outcomes. Data from the National Health Interview Survey as reported on January 2024 in NCHS Data Brief No. 490 indicate that in 2022, 5.7% of adults lacked reliable transportation for daily living in the past 12 months. Women (6.1%) were more likely than men (5.3%) to lack reliable transportation. The percentage of adults who lacked this means of traveling was lowest among Asian non-Hispanic adults (3.6%) compared with other race and Hispanic-origin groups. Lack of reliable transportation decreased with increasing education level and family income. Adults living in the West North Central region of the U.S.(7.5%) were more likely to lack reliable transportation than the national average (5.7%).  

HEALTH TECHNOLOGY CORNER 

Alzheimer’s Earlier Disease Detection

Many neurodegenerative diseases, including Alzheimer’s and Parkinson’s, are difficult to diagnose before symptoms begin to appear. Self-assembly of misfolded proteins can lead to the formation of amyloids, which are implicated in the onset of many pathologies including Alzheimer’s disease and Parkinson’s disease. The facile detection and discrimination of different amyloids are crucial for early diagnosis of amyloid-related pathologies. Disease-related biomarkers such as aggregated proteins called amyloids could provide important insight much earlier, however, if they can be readily detected. Researchers publishing on February 5, 2024 in the journal ACS Sensors described how they developed one such method using an array of sensor molecules that can light up amyloids. A fluorescent coumarin-based two-sensor array is able to  discriminate correctly between four different amyloids implicated in amyloid-related pathologies  The tool could help monitor disease progression or distinguish between different amyloid-related conditions.

The Fate Of Drug Discovery In Academia

Drug discovery is a tedious process taking a long time to divulge whether a molecule is efficacious and specific in hitting the target and then to confirm that the potential drug does not cause severe adverse effects. Many drug candidates fail crossing multiple checkpoints of this long journey, they lag in one or several aspects, and never move beyond the research bench to contribute to public health. Many drug development strategies are rather fuzzy in their advancement. Thus, there is a big gap between drug “discovery” and “development,” that could be attributed to the lack of synergy between academia and industry at multiple levels. A paper published on January 24, 2024 in Oncotarget discusses why many therapeutic molecules never make it to clinical studies despite being proven efficacious pre-clinically. Possible solutions to overcome this défaut of the drug development process also are discussed. Setbacks of this nature make the process of drug discovery time consuming, expensive, and tedious.  

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.  

HEALTH REFORM DEVELOPMENTS

As expressed in the January 2024 issue of the Disability and Health Journal, the 50th anniversary of the passage of the Rehabilitation Act of 1973 in 2023 marks a significant milestone in U.S. disability policy. In September 2023, the U.S. Department of Health and Human Services (HHS), through its Office for Civil Rights (OCR), issued a long-awaited proposed rule that updates nondiscrimination regulations enacted by the Rehabilitation Act of 1973. The rule strengthens prohibitions against discrimination on the basis of a disability in health care and human services programs. It makes significant updates to Section 504 of the Rehabilitation Act rule 50 years after the law was enacted to advance equity and strengthen protections for individuals with disabilities in this nation. Also, the year 2023 saw two additional potential shifts in U.S. disability policy.  

The National Institutes of Health (NIH) sought comments to eliminate the ableist language of “reducing disability” from the NIH mission statement. The proposed revised statement, “To seek fundamental knowledge about the nature and behavior of living systems and to apply that knowledge to optimize health and prevent or reduce illness for all people,” aims to remove any potentially ableist notions that these individuals inherently are flawed and need to be fixed. Additionally, in September 2023, the National Institute on Minority Health and Health Disparities (NIMHD), designated persons with disabilities as a population with health disparities for research supported by NIH. This designation represents an important shift and would allow for NIH investment in research that unambiguously focuses on disability and health disparities and incentivizes efforts to recruit researchers with disabilities and disabled people as participants in clinical research.  

Parity In Insurance Coverage Between Mental And Physical Health Care

Politico in January 2024 described efforts by former Congressman Patrick Kennedy (D-RI) who can see a path to his longtime goal of achieving parity in insurance coverage between mental and physical health care. An eight-term legislator who retired from the House at the end of 2010, he was the author of the 2008 Mental Health Parity and Addiction Equity Act that ordered insurers to cover mental health on the same terms as physical health. Unfortunately, what occurred after this law was enacted never quite evolved into what originally was envisioned. The former representative paid attention when insurers complained last year that the path to parity is blocked by workforce shortages. In response, he wants to convene labor unions, insurers, and the government to develop a way to boost the mental health workforce. He favors creating an AFL-CIO for addiction, adding that Congress can help with “an infrastructure bill” for mental health. He also sees a bigger role for community mental health centers, initially funded under the last piece of legislation (P.L. 88-164, Community Mental Health Act of 1963), his uncle, President John F. Kennedy, signed into law on October 31 before his assassination. He wants community behavioral health centers to integrate with physical health centers to better serve Americans with mental health issues.

Historic Selection Of ACA Marketplace Health Insurance Coverage

The Centers for Medicare & Medicaid Services on January 24, 2024 announced that 21.3 million individuals selected an Affordable Care Act (ACA) Health Insurance Marketplace plan during the 2024 Open Enrollment Period. Total plan selections include more than five million beneficiaries — about a fourth — who are new to the Marketplaces and 16 million others who renewed their coverage. The Biden Administration has continued its commitment to making health insurance available and affordable to everyone. The Inflation Reduction Act (IRA) and the American Rescue Plan continue to keep Marketplace coverage affordable. Thanks to the IRA, four in five HealthCare.gov customers were able to find health care coverage for $10 or less per month for plan year 2024 after subsidies. Compared to the Open Enrollment Period last year, nearly 4.2 million more individuals with household incomes less than 250% of the federal poverty level (about $75,000 per year for a family of four) enrolled in 2024 coverage, demonstrating that when coverage is affordable, beneficiaries enroll. Marketplace coverage also has been critical for many individuals transitioning from Medicaid or the Children’s Health Insurance Program (CHIP) as states conduct eligibility renewals, which restarted last year.  Additionally, almost $100 million in Navigator Awards were issued, allowing organizations to hire staff trained to help consumers find affordable, comprehensive health coverage. Navigators, as they are known, have been key to helping consumers in every Marketplace state. 

IMPROPER PANDEMIC PROGRAMS PAYMENTS

A report (R47902) issued on January 19, 2024 by the Congressional Research Service describes improper payments made in Pandemic Assistance Programs. Congress provided approximately $4.6 trillion to individuals, businesses, and state and local governments to mitigate the impact of the COVID-19 pandemic on the nation’s health system and economy. The federal agencies that administer those funds are subject to the Payment Integrity Information Act (PIIA, P.L. 116-117), which requires them to develop and implement internal controls that prevent and detect fraud and other improper payments. One requirement is agencies must verify the identities and eligibility of individuals and organizations seeking pandemic funding prior to issuing payments, by specifically accessing the Department of the Treasury’s Do Not Pay (DNP) resource.  

PIIA also requires agencies to implement the fraud control principles and leading practices outlined in A Framework for Managing Fraud Risks in Federal Programs, which was published by the Government Accountability Office (GAO) in 2015. The leading practices include performing timely program risk assessments, maximizing the use of data analytics to prevent and identify fraud, and establishing an office within each agency that leads its anti-fraud efforts. PIIA also mandates that agencies determine the risk of significant improper payments associated with each program, estimate the amount of improper payments for each risk-susceptible program, and publicly report those estimates and other improper payments information.  

Audits of pandemic programs have found that many agencies did not meet PIIA requirements, resulting in hundreds of billions of dollars in fraud and other improper payments. Among the most widespread weaknesses in pandemic programs was the lack of effective pre-payment controls. Several agencies allowed businesses and individuals to self-certify their information, meaning the agencies did not verify the identities or eligibility of applicants through DNP or other means prior to issuing payments. Similarly, many state agencies that administered federal pandemic funds, such as with the Unemployment Insurance program, did not conduct pre-payment verification of claimants. Some agencies also did not implement effective post-payment controls, such as reviewing documentation to verify that payments had been made to eligible entities for covered costs or establishing procedures to recover overpayments.  

Several agencies that administered some of the largest pandemic programs did not meet the anti-fraud standards of the framework. Among the most common weaknesses were a lack of timely fraud risk assessments and the absence of a dedicated anti-fraud entity within the agency. The consequences of large-scale fraud extend beyond the loss of funds. American businesses and individuals who were eligible for loans or benefits were unable to obtain assistance because the programs ran out of funding. Moving forward, consistent with H.R. 8322 from the 117th Congress, legislation might be introduced that would establish a central anti-fraud entity to share leading practices and oversee implementation of cutting-edge data analytic tools across the government.  

NAVIGATING THE METAVERSE

As the health domain continues to undergo significant change, the professional literature exhibits many ways in which the metaverse has the potential to modify health care delivery and enhance individual and community health status. The term metaverse has its provenance in the novel Snow Crash by the science fiction writer Neal Stephenson in 1992. According to a pair of articles published in the January and October 2023 issues of the Journal of Neuropsychiatry and Clinical Neurosciences by López and Hurley, the metaverse denotes a digital platform as a new and alternative environment manifested through digital content delivered via advanced technological devices employing artificial intelligence (AI). 

This platform encompasses highly immersive and collaborative environments based on three-dimensional and real-time digital worlds in which multiple users can engage in activities (e.g., social, economic, and cultural). The authors indicate that the medical metaverse and its emerging technologies, such as AI, are transforming medical education, neuropsychiatric practice, and clinical neurosciences. AI provides earlier detection of many diseases and facilitates the clinical management of physical and mental conditions. 

Viewed from another perspective, according to a manuscript published on August 24, 2023 in the journal Frontiers in Rehabilitation Sciences by Veras, metaverse technology is spurring a transformation in health care and has the potential to cause a disruptive shift in rehabilitation interventions. The technology surely will be a promising field offering new resources to improve clinical outcomes, compliance, sustainability, and patients’ interest in rehabilitation. For example, virtual reality (VR) has been used in several areas of physical therapy, occupational therapy, and speech therapy to improve upper limb function in stroke survivors, hand therapy, pain management, rehabilitation from COVID-19, lower back pain, balance treatment, cognition, communication, and acquired brain injury rehabilitation. Additionally, augmented reality (AR) is used in combination with conventional therapy for the treatment of balance and fall prevention in older adults; lower and upper limb functionality in stroke; phantom pain syndrome; and treatment for gait freezing in those with Parkinson’s disease. Nonetheless, an important caveat is that despite the growing interest in technologies for rehabilitation, various barriers to using digital services may continue to perpetuate a digital divide. 

Also, as Hulsen, notes in a paper published on December 29, 2023 in the periodical Advances in Laboratory Medicine, in medicine and health care, the metaverse could be used in several ways: (1) virtual medical consultations; (2) medical education and training; (3) patient education; (4) medical research; (5) drug development; (6) therapy and support; and (7) laboratory medicine. The metaverse has the potential to enable more personalized, efficient, and accessible health care, improving patient outcomes and reducing health care costs. It is essential to realize, however, that the implementation of the metaverse in medicine and health care will require careful consideration of ethical and privacy concerns, as well as social, technical, and regulatory challenges.  

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Availability of Mental Telehealth Services in the U.S.

Telehealth availability for mental health care varies significantly across states, according to a new RAND study. The findings were published in the journal JAMA Health Forum on February 2, 2024. Of the 1,221 facilities (87%) accepting new patients, 980 (80%) reported offering telehealth. Of these, 97% (937 facilities) reported availability of counseling services; 77% (726 facilities), medication management; and 69% (626 facilities) diagnostic services. Telehealth availability did not differ by clinical condition. Researchers found there were differences in services offered depending on whether a mental health treatment facility was located in a rural or metropolitan area. The types of services offered, and the types of telehealth modalities available, also varied widely among clinics, with roughly one in four clinics not offering virtual medication management and about one in three not offering virtual diagnostic services. No significant differences occurred based on the callers’ perceived race and ethnicity. 

Lack Of Reliable Transportation For Daily Living Among Adults: United States, 2022

Access to transportation may be required for many daily tasks, including going to work and health care visits. Previous research suggests that a lack of transportation, especially among adults who are older, uninsured, and have lower incomes, leads to reduced access to health care, and adverse health outcomes. Data from the National Health Interview Survey as reported on January 2024 in NCHS Data Brief No. 490 indicate that in 2022, 5.7% of adults lacked reliable transportation for daily living in the past 12 months. Women (6.1%) were more likely than men (5.3%) to lack reliable transportation. The percentage of adults who lacked this means of traveling was lowest among Asian non-Hispanic adults (3.6%) compared with other race and Hispanic-origin groups. Lack of reliable transportation decreased with increasing education level and family income. Adults living in the West North Central region of the U.S.(7.5%) were more likely to lack reliable transportation than the national average (5.7%).  

HEALTH TECHNOLOGY CORNER 

Alzheimer’s Earlier Disease Detection

Many neurodegenerative diseases, including Alzheimer’s and Parkinson’s, are difficult to diagnose before symptoms begin to appear. Self-assembly of misfolded proteins can lead to the formation of amyloids, which are implicated in the onset of many pathologies including Alzheimer’s disease and Parkinson’s disease. The facile detection and discrimination of different amyloids are crucial for early diagnosis of amyloid-related pathologies. Disease-related biomarkers such as aggregated proteins called amyloids could provide important insight much earlier, however, if they can be readily detected. Researchers publishing on February 5, 2024 in the journal ACS Sensors described how they developed one such method using an array of sensor molecules that can light up amyloids. A fluorescent coumarin-based two-sensor array is able to  discriminate correctly between four different amyloids implicated in amyloid-related pathologies  The tool could help monitor disease progression or distinguish between different amyloid-related conditions.  

The Fate Of Drug Discovery In Academia

Drug discovery is a tedious process taking a long time to divulge whether a molecule is efficacious and specific in hitting the target and then to confirm that the potential drug does not cause severe adverse effects. Many drug candidates fail crossing multiple checkpoints of this long journey, they lag in one or several aspects, and never move beyond the research bench to contribute to public health. Many drug development strategies are rather fuzzy in their advancement. Thus, there is a big gap between drug “discovery” and “development,” that could be attributed to the lack of synergy between academia and industry at multiple levels. A paper published on January 24, 2024 in Oncotarget discusses why many therapeutic molecules never make it to clinical studies despite being proven efficacious pre-clinically. Possible solutions to overcome this défaut of the drug development process also are discussed. Setbacks of this nature make the process of drug discovery time consuming, expensive, and tedious.  

IMMIGRATION, SDoH, THE MICROBIOME, AND HEALTH OUTCOMES

As reported in the January 2024 issue of the American Journal of Biological Anthropology, Fanfan and associates adapted the National Institute on Minority Health and Health Disparities' research framework to propose a conceptual model that considers the intersection of SDoH, the microbiome, and health outcomes in immigrants. This conceptual approach was used as a lens through which to explore recent research about SDoH, biological factors associated with changes to immigrants' microbiomes, and long-term health outcomes. Seventeen articles were reviewed, indicating that dietary acculturation; physical activity; ethnicity; birthplace; age at migration and length of time in the host country; socioeconomic status; and social/linguistic acculturation were important determinants of postmigration microbiome-related transformations. These factors are associated with progressive shifts in microbiome profile with time in host country, increasing the risks for cardiometabolic, mental, immune, and inflammatory disorders and antibiotic resistance. The evidence thus supports the premise that SDoH influence immigrants' health postmigration, at least in part, through their effects on the microbiome.  

Omission of important postmigration social-ecological variables (e.g., stress, racism, social/family relationships, and environment), limited research among minoritized subgroups of immigrants, complexity and inter- and intra-individual differences in the microbiome, and limited interdisciplinary and biosocial collaboration restrict an understanding of this area of study. To identify potential microbiome-based interventions and promote immigrants' well-being, more research is necessary to understand the intersections of immigrant health with factors from the biological, behavioral/psychosocial, physical/built environment, and sociocultural environment domains at all social-ecological levels. The authors point out that international migrants number more than 272 million individuals out of a global population of more than 7.7 billion. Global conflict, environmental disasters, economic necessity, and the desire for a better life will continue to drive high levels of migration worldwide. Although immigrants from less-developed to more-developed countries tend to have better health in birth outcomes, cardiometabolic health, and mental health relative to native-born populations upon migration, compelling evidence demonstrates that this health advantage erodes with increased time in the host country.

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.