HEALTH REFORM DEVELOPMENTS

HEALTH REFORM DEVELOPMENTS 

The health domain consists of key aspects involving health professions education, patient care, and clinical research. As noted in a paper published on March 21, 2024 in the journal JAMA Oncology, minority and socioeconomically disadvantaged population subgroups are underrepresented in clinical trials. That fact may reduce the generalizability of trial results and propagate health disparities, which leads to the necessity of focusing on social determinants of health (SDoH) as a means of making needed improvements. Examples of SDoH are low levels of education, lack of employment opportunities, and unsafe neighborhoods.  

The March 2024 issue of The Milbank Quarterly contains an article that highlights the negative influence played by the lack of adequate transportation as a SDoH. The authors propose applying a more holistic transportation justice framework to systemic problems in health care. They suggest ways to advance the impact of transportation interventions and highlight the limitations of how health  services researchers and practitioners currently conceptualize and use transportation. Incorporating a transportation justice framework offers an opportunity to address transportation and mobility needs more comprehensively and equitably within health care research, delivery, and policy. 

Limiting The Availability Of Junk Health Insurance Plans

Since the Patient Protection And Affordable Care Act (ACA) became law in March 2010, efforts have been made to provide coverage for the uninsured and to make health care more affordable. A concern is that some beneficiaries are purchasing lower quality insurance, or “junk insurance plans” that discriminate based on pre-existing conditions and provide little or no coverage. On March 28 of this year, the Departments of Health and Human Services, Labor, and the Treasury (collectively, the Departments) released the Short-Term, Limited-Duration Insurance and Independent, Noncoordinated Excepted Benefits Coverage, or Junk Insurance Final Rules. Short-term, limited-duration insurance (STLDI) is a type of health insurance that typically is designed to fill temporary gaps in coverage when an individual is transitioning from one source of coverage to another. Unlike most health insurance plans, STLDI plans are not subject to the ACA’s critical consumer protections, including guaranteeing  coverage for individuals with pre-existing conditions and prohibiting discrimination based on health status, age, or gender. These final rules will limit “short-term” plans to truly short-time periods, no more than four months instead of three years.  

Primary Care In The U.S. And Nine Other Nations

An Issue Brief released by The Commonwealth Fund in March 2024 posits that despite the importance of primary care, health systems around the world are facing challenges at the patient and provider level. Many nations struggle to ensure access to care, or first contact; continuity of care; comprehensiveness of care; and coordination of care. These four core components of high-quality primary care are essential to achieve better overall health outcomes. Factors, such as workforce shortages and growing administrative burdens, pose significant barriers to care. The Brief compares the state of primary care in the United States with nine other high-income nations. It updates an earlier Commonwealth Fund study comparing primary care performance in the U.S. with nine peer countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, and the United Kingdom.  

The findings reveal that although 86% or more of respondents in all 10 countries reported having a regular doctor or place to go for care, adults in the U.S., Sweden, and Canada had the lowest rates, and U.S. adults were the least likely to have a longstanding relationship with a primary care provider. Less than a third of U.S. primary care providers reported making home visits compared to more than two-thirds in all other surveyed countries. Physicians in the U.S. and Germany were most likely to screen their patients for social needs, such as housing and food insecurity. Fewer than four in 10 physicians in the U.S., Sweden, the Netherlands, and Germany reported adequate coordination with specialists and hospitals regarding changes to their patients’ care. A conclusion is that the U.S. trails its peers, particularly in access to and continuity of care. Patients in the U.S. are among the least likely to have access to primary care outside of regular business hours or a longstanding relationship with their primary care physician.

FEDERAL FUNDING SECURED FOR FY 2024

It took six months to complete the task, but Congress finally was able to finish all the steps necessary to produce a $1.3 trillion package of 12 spending bills to be signed into law by President Joseph Biden for the fiscal year that began on October 1, 2023. Democrat and Republican members in both legislative chambers were able to identify specific aspects of the various bills that engendered a feeling of satiety, while also acknowledging that there are several areas that will be added to the wish list when developing appropriations for the next fiscal year. For the current fiscal year, the results include: 

Health Resources and Services Administration (HRSA) Title VII and Title VII Health Professions Education and Training programs would receive $815.8 million, a $6 million (7.0%) increase over FY 2023 enacted levels. The bill also would boost discretionary funding for the National Health Service Corps ($128.6, a $3 million or 2.3% increase. The bill would provide $9.2 billion for the Centers for Disease Control and Prevention, a $4.5 million (0.5%) increase, and would provide $369 million, a $4.5 million (1.2%) cut, to the Agency for Healthcare Research and Quality. The total program level for NIH’s base would be $47.081 billion, $378 million (0.8%) below the comparable FY 2023 funding level. The reduction is the result of a scheduled decrease in funding available to NIH in FY 2024 through the 21st Century Cures Act.  

As a way of proceeding to develop spending bills for FY 2025, which begins next October 1, the President’s budget proposal, referred to by statute as the Budget of the United States Government, is required by law to be submitted annually, according to the Congressional Research Service (CRS). The President’s budget submission in practice is a statement of the Administration’s policy priorities and a unified plan for the allocation of federal budgetary resources. The President’s budget is a set of recommendations that Congress may consider, but is not required to adopt, however, it usually initiates the congressional budget process. Under current law, the President must develop and submit a consolidated budget to Congress no later than the first Monday in February prior to the start of the upcoming fiscal year. 

The President’s budget has become one of the institutional presidency’s most significant policy tools. Through the executive budget process, the President may set forth legislative and program objectives and attempt to influence the nation’s overall fiscal course. A wide range of agencies support the President in the process of formulating the budget proposal. Specifically, the Office of Management and Budget (OMB) is largely responsible for assisting the President in carrying out  budgetary duties. Along with OMB, the Council of Economic Advisors and the Treasury Department provide economic projections and revenue estimates. OMB coordinates the development of the President’s budget proposal by issuing circulars, memoranda, and guidance documents to the heads of executive agencies. These entities may then prepare their budget requests in accordance with the instructions and guidance provided by OMB.

USES OF ARTIFICAL INTELLIGENCE (AI) IN HEALTH CARE

A cursory inspection of the health professions literature reveals a burgeoning presence of articles discussing the ways in which artificial intelligence (AI) can be integrated productively in the relam of health care. For example, Barwise and co-investigators in the March 2024 issue of the Journal of the American Medical Informatics Association assert that inpatients with language barriers and complex medical needs suffer disparities in quality of care, safety, and health outcomes. Although in-person interpreters are particularly beneficial for these patients, they are underused. Consequently, this research team plans to use machine learning predictive analytics to identify patients with language barriers and complex medical needs to prioritize them for in-person interpreters. They believe that such efforts are the first study that elicits stakeholder perspectives on the use of AI with the goal of improved clinical care for patients with language barriers.  

On the mental health care side of the ledger, a paper by Dakanalis et al in the February 2024 issue of Cyberpsychology, Behavior, and Social Networking examines the potential of AI to revolutionize mental health care. The text discusses the rapid evolution of AI, particularly in image analysis for early physical health diagnoses, and its promising applications in mental health, including predictive analytics for various disorders. The article advocates for AI as a complementary tool rather than a replacement for human involvement in mental health services.  

Abadir and Chellappa in their article in the February 2024 issue of The Journals of Gerontology: Series A Biological Sciences & Medical Sciences view the integration of AI as a potentially transformative force. The future will require multidisciplinary collaboration among clinicians, AI engineers, and key stakeholders, including patient advocacy groups and older adults, to develop solutions that address the complex nature of aging effectively. A course is charted for an upcoming special issue in The Journals of Gerontology on AI-enabled wearables and sensors for older adults.  

THERAPEUTIC MISUNDERSTANDINGS IN MODERN RESEARCH

Failing to understand the distinction between research and clinical care, and the likelihood of benefit from participation in clinical trials is referred to as the “therapeutic misconception.” As described in a manuscript by Heynemann et al appearing in the February 2024 issue of the journal Bioethics, four decades have passed since the phenomenon termed the ‘therapeutic misconception’ first was described in the context of evaluation of participants' understanding of a randomized controlled trial (RCT) of a psychotropic agent. These investigators indicate that clinical trials play a crucial role in generating evidence about health care interventions and improving outcomes for current and future patients. A concern for individual trial participants, however, is that inevitably there are trade-offs involved in clinical trial participation, given that trials traditionally have been designed to benefit future patient populations rather than to offer personalized care. The evolution of the clinical trials landscape, including greater integration of clinical trials into health care and development of novel trial methodologies, may reinforce the significance of the therapeutic misconception and other forms of misunderstanding while at the same time (paradoxically) challenging its salience.  

Using cancer clinical trials as an example, the researchers describe how methodological changes in early- and late-phase clinical trial designs, as well as changes in the design and delivery of health care, have an impact upon the therapeutic misconception. They suggest that such changes provide an impetus to re-examine the ethics of clinical research, particularly in relation to trial access; participant selection; communication and consent; and role delineation. The central problem to which the therapeutic misconception draws attention is the conflation of clinical research with clinical care, two rather different enterprises with vastly different goals. Persistent conceptual challenges surrounding the therapeutic misconception and related misunderstandings are considered in the article. Next, some emerging and, as yet, unexamined implications for the therapeutic misconception with the evolution of clinical trial designs and the widespread movement towards seamless integration of clinical research into clinical care are highlighted . An intention is to deconstruct a well-recognized concept within research ethics, contextualize it in the modern clinical trials landscape, and offer some preliminary practical suggestions for operationalizing these ideas. 

TECHNOLOGY AND HEALTH CARE

Similar to what is occurring in other sectors of the U.S. economy, developments in technology already play a role in transforming the health care sphere. Artificial intelligence and virtual reality are expected to continue making significant inroads in health professions education and patient care. Another facet of technology that also attracts increased attention is patient wearables. The New England Journal of Medicine is one of many periodicals that has had a focus on this topic. A final review of a series on wearable digital health technologies (DHTs) appeared in the March 21, 2024 issue. 

It highlights important challenges that must be met to integrate these devices into clinical guidelines and practice. The narrative deliberately is grounded in what is possible today, but speculations also are made about specific uses of wearable DHTs in the future. Six interlocking and vexing issues are identified as being at the foundation of delivering DHT-informed care. They are:  

Data Ownership

Who owns the raw and derivative data obtained from wearable DHTs? Ownership can be unclear, since data collection involves multiple stakeholders, including patients, device manufacturers, app providers, and data aggregators.  

Patient Trust, Literacy, and Access

Fear that personal health data may be compromised or misused, especially with the increasing use of AI, is one of the most important trust issues.   

Standards and Interoperability

Although the broad field of DHTs, which includes electronic health records and telemedicine, has adopted data standards, the field of wearable DHTs, which is characterized by ongoing development, lacks such standards.  

Integration into Clinical Environments

Integrating wearable DHTs into clinical care presents several workflow challenges that can affect both health care professionals and patients. One of the biggest challenges is the sheer volume of data generated by wearable DHTs, which can be overwhelming.  

Patient Empowerment and Agency

For patients to have agency and empowerment in using data from their wearable DHTs, the challenges of control over the data, an understanding of how the data can be used effectively, and trust in the systems managing the data will need to be addressed.  

Reimbursement and Return on Investment for Health Care Systems

A set of Current Procedural Terminology (CPT) codes exists for remote patient monitoring with wearables. Devices and procedures that do not meet existing CPT definitions still present serious challenges in securing reimbursement.   

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Deaths From Excessive Alcohol Use—United States, 2016-2021

Deaths from causes fully attributable to alcohol use (i.e., 100% alcohol-attributable causes, such as alcoholic liver disease and alcohol use disorder) have increased during the past two decades in the United States. Rates were particularly elevated from 2019 to 2020, concurrent with the onset of the COVID-19 pandemic. According to data furnished in the February 29, 2024 issue of the Morbidity And Mortality Weekly Report, average annual number of deaths from excessive alcohol use, including partially and fully alcohol-attributable conditions, increased approximately 29% from 137,927 during 2016–2017 to 178,307 during 2020–2021, and age-standardized death rates increased from approximately 38 to 48 per 100,000 population. During this time, deaths from excessive drinking among males increased approximately 27%, from 94,362 per year to 119,606, and among females increased approximately 35%, from 43,565 per year to 58,701.

Cancer Statistics, 2024

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population-based cancer occurrence and outcomes using incidence data collected by central cancer registries (through 2020) and mortality data collected by the National Center for Health Statistics (through 2021). According to the January/February 2024 issue of CA, A Cancer Journal for Clinicians, in 2024, 2,001,140 new cancer cases and 611,720 cancer deaths are projected to occur in the United States. Cancer mortality continued to decline through 2021, averting over four million deaths since 1991 because of reductions in smoking, earlier detection for some cancers, and improved treatment options in both the adjuvant and metastatic settings. These gains are threatened, however, by increasing incidence for six of the top 10 cancers (e.g., breast, pancreas, uterine corpus cancers, prostate, liver (female), and kidney). 

HEALTH TECHNOLOGY CORNER 

Ant’s Biting System And Surgical Needle Holders

Over the millennia, humans have benefited from learning about the use of medications and other kinds of health interventions by observing animal behavior. As described in the February 27, 2024 issue of the Proceedings of the National Academies of Science of the USA, researchers at the University of California, Berkeley noted that the grasping and holding tools of robotics, microassembly, or endoscopic surgery operate in confined spaces. This fact limits their maximum size and performance. The investigators studied one of nature’s solutions for this problem: the ant’s mandibles, which combine strong biting performance with elaborate maneuverability of objects. Their mandibles are characterized by gliding joints, tilting axes, and changing power transmission during the opening and closing process. These three design principles then were transferred to a commercially available surgical needle holder. The result is that the grasping performance of the needle holder is improved substantially. 

Robotic Surgery For Gall Bladder Cancer

Surgery is the most promising curative treatment for patients diagnosed with gall bladder cancer, Although there has been increasing adoption of minimally invasive surgical techniques in gastrointestinal malignancies, including utilization of laparoscopic and robotic surgery, there are reservations in utilizing minimally invasive surgery for gallbladder cancer. Published on February 27, 2004 in The American Journal of Surgery, researchers at the Boston University School of Medicine found that robotic-assisted surgery for this kind of cancer is as effective as traditional open and laparoscopic methods, with added benefits in precision and quicker post-operative recovery. Robotic-assisted resection safely and effectively treats gallbladder cancer. This intervention achieves equivalent oncologic outcomes compared to open and laparoscopic approaches. Technical advancements in robotic surgery enhance dexterity and precision during procedures. Further research is warranted to confirm its benefits and establish surgical guidelines.  

DEVELOPMENTS IN HIGHER EDUCATION

The Biden Administration on February 21 announced that it automatically will discharge $1.2 billion in loans for nearly 153,000 borrowers who are eligible for the shortened time to forgiveness benefit under the Saving on a Valuable Education (SAVE) Plan. This action comes as 7.5 million borrowers are enrolled in SAVE, 4.3 million of whom have a $0 monthly payment. The action represents a clear message to borrowers who had low balances, informing them that they have done their part and deserve relief. Previously, the Administration announced in January that the shortened time to forgiveness component of the SAVE Plan would be accelerated nearly six months earlier than anticipated in order to provide these individuals the relief they have earned as quickly as possible. For borrowers to be eligible for this forgiveness they must be enrolled in the SAVE Plan, have been making at least 10 years of payments, and originally have taken out $12,000 or less for college. For every $1,000 borrowed above $12,000, a borrower can receive forgiveness after an additional year of payments. 

All borrowers on SAVE receive forgiveness after 20 or 25 years, depending on whether they have loans for graduate school. The benefit is based upon the original principal balance of all federal loans borrowed to attend school, not what a borrower currently owes or the amount of an individual loan. Individuals who meet the eligibility criteria for forgiveness under the SAVE Plan will have their loans automatically discharged with no action needed on their part. Thus far under the current Administration, the following amounts also have been approved: $56.7 billion for more than 793,000 borrowers through fixes to Public Service Loan Forgiveness (PSLF); $45.6 billion for 930,500 borrowers through improvements to income-driven repayment; $11.7 billion for 513,000 borrowers with a total and permanent disability, including the provision of automatic discharges off a data match with the Social Security Administration; and $22.5 billion for 1.3 million borrowers through closed school discharges, borrower defense, and related court settlements.

Final Negotiated Rulemaking Session Of A USDE Committee On Institutions And Programs

A final negotiated rulemaking session of the U.S. Department of Education’s Institutional Quality and   Program Integrity Committee occurred on March 4 through March 7, 2024. Three of the six topics in the discussion focus on Accreditation, State Authorization, and Distance Education. Following this session, the negotiator’s comments and a draft a Notice of Proposed Rulemaking (NPRM) will be made available. The latter item will be published in the Federal Register, making it possible for interested parties and the public to provide comments. A goal is to publish the final rule by November 1, 2024, with implementation set for July 1, 2025. 

Enhancing Educational And Employment Opportunities In Rural Areas

The many positive aspects of living in a rural area may be partially offset by challenges associated with not having ready access to health resources, higher education institutions, and well-paying jobs. An analysis of this situation is provided in a new report from the Georgetown University Center on Education and the Workforce. Entitled “Small Towns, Unique Opportunities,” the document offers a countervailing view to a popular narrative that rural America has been “left behind.” The rural workforce in the U.S consists of up to 13% of the total 25-to-64-year-old working population and holds 12%, or a roughly proportionate share, of the country’s good jobs. It also provides recommendations to mitigate the region’s high labor-force non-participation rate (26%), low bachelor’s degree attainment rate (25%), and overall population decline. Rural areas have strengths that can be built upon with additional investments. To ensure rural workers have access to good jobs, efforts should be implemented to make education and training more easily available to rural residents, while simultaneously investing more in the skills that these individuals already possess. It also would be beneficial to plan ahead for rural growth. Technology is allowing a larger segment of members of the public to work from wherever they want, while the less-crowded, less-expensive rural lifestyle will continue to be attractive for many individuals.  

HEALTH REFORM DEVELOPMENTS

The U.S. has a lengthy history of government involvement in the health domain. Legislation was enacted in 1798, authorizing the provision of medical care for merchant seamen and for establishing the U.S. Marine Hospital. By 1799, federal state cooperation produced efforts to enforce quarantine laws to stem the spread of infectious diseases, e.g., cholera and yellow fever. The 20th century entailed major achievements including creation of the NIH and efforts to improve the health workforce. The Roosevelt Administration in the 1930s and 1940s reflected efforts to expand health insurance coverage for the entire population of this country. By the early 1990s, it became evident that the major focus should not be only on insurance coverage, but also on improving health care quality and controlling a steady rise in the growth of health care costs. 

Unfortunately, this last item does not always attract the attention it warrants in the policy arena. Overall, the nation has a debt of $34 trillion. It grows each year because revenues are less than expenditures. According to a report issued on February 15, 2024 by the Government Accountability Office (Report GAO-24-106987), when the government spends more than it collects in revenue, it borrows to finance the resulting deficit by issuing debt to the public. The fiscal year 2023 deficit was $1.7 trillion, the fourth year in a row above $1 trillion. The deficit is composed of two parts: the  primary deficit, the gap between program spending and revenue, which was about $1 trillion in fiscal year 2023. Also, net interest spending, primarily the cost to service the debt, was $659 billion that fiscal year. A result is that such money cannot be used for more constructive endeavors. Primary deficits are projected to grow over the long term, in large part because of projected increases in spending for Medicare, other federal health care, and Social Security programs compared to relatively lower projected increases in revenue. Proposed solutions are not pleasant and may involve increasing taxes, eliminating popular features of entitlement programs, and changing program eligibility standards, e.g., raising the age for obtaining benefits. 

Insurance Consequences Of Biomarker Testing

A fascinating aspect of the health care arena is that there is a steady flow of new technologies and services that have a significant influence on expenditures. Some new medications can result in monthly costs of hundreds of thousands of dollars, which are well beyond the ability of patients to pay for them. Even for drugs that are curative and life saving, how will such costs be financed? A related consideration involves diagnostics. Based on a paper by Arias et al in the February 2024 issue of JAMA Neurology, evidence-based and empirical legal research is needed to develop policy solutions that could mitigate the risk for individuals at risk of discrimination based on biomarker status. Privacy, confidentiality, and anti-discrimination protections are not yet equipped to mitigate potential discrimination risks. 

Conscientious Guardian vs. Commercialized Jungle

Apart from the Apple technology product marvels resulting from the work of Steve Wozniak and Steve Jobs in a garage in Redondo Beach, CA, advances in health care have been part of the many changes affecting society. Readers of this newsletter who have grown long in the tooth may recall how common it once was for every neighborhood to have a pharmacy, owned and operated by the individual who served as its founder. The establishment typically bore the name of that person, such as Banville’s Drug Store. When druggist Banville was not in a side room creating a prescription using a mortar and pestle, he might be at the 4-5 stool ice cream section of the store dishing out cones and milk shakes in as many as four different flavors. This individual always could be counted on to assist low income patrons by lancing a boil on a child’s neck at no fee or allowing a grandparent to borrow a cane from the store when that kind of assistance device was needed. Moving ahead to 2024, those establishments have vacated the American scene and been replaced by national chain drug stores that occupy much larger real estate spaces. An article by Richert and Carter in the January 2024 issue of the Journal of the History of Medicine and Allied Sciences focuses on a central debate between pharmacists during the postwar period about how pharmacies were shifting from the role of healer to that of a retailer, from a “conscientious guardian” to a “commercialized jungle,” to highlight how the public health role of pharmacies was undermined by industry pressures for profit. 

TOTTERING, BUT STILL STANDING

As they have performed repeatedly over the years, when it comes to the essential task of passing spending legislation to enable the federal government to continue functioning, members in both congressional chambers realize it may not be in anyone’s best interest to approach too closely to the edge of a metaphorical abyss. To produce 12 spending bills for fiscal year 2024, which began on October 1 last year, Congress recently was able to pass an additional continuing resolution (H.R. 7463) on February 29 with the House approving the measure by a vote of 320-99 and by 77-13 in the Senate. The CR extends fiscal year (FY) 2023 funding for four annual spending bills, including the Military Construction and Veterans Affairs spending bill through March 8, while continuing FY 2023 funding for the other eight spending bills, including the Labor, Health and Human Services, and Education and Defense bills until March 22. 

Daily reports from the National Journal provide good snapshots of what is unfolding. Congress on March 3 released a package of six government bills that would fund a half-dozen agencies for the remainder of the fiscal year through September 30. The next hurdle is passing the package in both chambers ahead of a shutdown looming on March 8 at midnight. The $460 billion package for FY 2024 is the culmination of months of negotiations between congressional leaders that entailed a contentious appropriations process that saw multiple stopgap funding measures, and threatened several near-shutdowns.  

The latest bipartisan package includes funding for the Agriculture, Interior, Energy, Veterans Affairs, Transportation, and Housing and Urban Development departments, the Environmental Protection Agency, and the Food and Drug Administration. Passage is expected. Lawmakers then immediately must pivot and fund the rest of the government by March 22, a new date members secured with the continuing resolution. If they fail to pass all 12 appropriations bills by April 30, a 1%, across-the-board cut to federal discretionary spending, essentially everything but entitlement programs would go into effect. Although the funding bill for the Health and Human Services Department (HHS) was not a part of this deal (its funding runs out March 22), lawmakers managed to include an increase to doctors’ pay under Medicare. Specifically, the agreement would change the pay increase from 1.25% to 2.93%. The arrangement only partially offsets the 3.4% reduction in payment that became effective at the beginning of this year. 

Not to be forgotten is the high drama that preceded attempts to pass all 12 spending bills. Unhappiness with the performance of Rep. Kevin McCarthy (R-CA), who was criticized by members of his party’s  Freedom Caucus for failing to oppose a bipartisan approach to government funding and not being successful in enacting steep budgetary cuts, he lost his position as House speaker. He was succeeded by Michael Johnson, a relatively unknown colleague from Louisiana. Oddly enough, the latter will function in the same manner that affected his predecessor adversely. A single vote to vacate the chair also could end Speaker Johnson’s occupancy of that position.  

WHY WORD PRECISION MATTERS

Periodically, this newsletter serves as a vehicle for discussing how terminology inexactitudes can have a detrimental impact on health care quality. For example, the December 2023-January 2024 issue described how inconsistent use of terms, such as Alzheimer disease and dementia has compromised progress in clinical care, research, and development of therapeutics.  

Also, from a much wider perspective, the October 2024 issue referred to how conceptual opacity characterizes the word “health.” Because of this opaqueness, health tacitly is defined narrowly as the absence of disease. The result is a perpetuation of a biomedical paradigm in health care with a focus on diagnosing and treating disease. This tacit definition yields poor investment in the inherent health potential of individuals relative to drugs and technology, thus fostering a misalignment between the goals of health care and the goals of individuals, communities, public health, and society. 

A more recent example is provided regarding the term pain, a condition familiar to members of the entire human family irrespective of other demographic characteristics that differentiate them from one another. The March 2024 issue of the Journal of Pain includes a focus on the term “pain catastrophizing.” A paper by Sullivan and Tripp discusses how recent reports have pointed to problems with the term “pain catastrophizing.” Critiques of that designation have come from several sources including individuals with chronic pain, advocates for individuals with chronic pain, and pain scholars. Reports indicate that the term has been used to dismiss the medical basis of pain complaints, to question the authenticity of pain complaints, and to blame individuals with pain for their pain condition. These co-authors advance the proposition that problems prompting calls to rename the construct of pain catastrophizing have little to do with the term, and as such, changing it will do little to solve these problems. Moreover, they argue that continued calls for changing or deleting the term pain catastrophizing will only divert attention away from some fundamental flaws in how individuals with pain conditions are assessed and treated.   

Conroy and Webster in their article in that journal issue underscore these views by maintaining that indeed, language does matter. The argument that the term itself is not problematic perhaps reflects an underestimation of the role of language in shaping understandings of the world. They posit that language not merely describes, but in fact shapes how objects become known. A survey they conducted pertaining to pain catastrophizing revealed how the term was understood to be problematic by many individuals living with pain insofar as they perceived it to invalidate their experiences and confer stigma. The issue is not confined to clinician education and the use of patient-centered language in the clinical visit. Rather, it extends to public education; media and press stories about scientific work; and social media visibility of scientific work where patients, scientists, and clinicians communicate in a public and open forum.  

WOMEN’S HEALTH THROUGHOUT THE LIFE COURSE

Acknowledging that women’s health remains underserved by the medical research community, and the impacts of sex differences and sociocultural factors on the health and wellbeing of women are rarely considered, the January 2024 issue of the journal Nature Medicine launched a “Series on Women’s Health.” The first installment by Carcel et al presents a Perspective calling for a life-course approach to the prevention and treatment of non-communicable diseases (NCDs) in women. The authors assert that women’s health has been critically underserved by a failure to look beyond their sexual and reproductive systems to consider their broader health needs adequately. In almost every country in the world, NCDs are the leading causes of death for women. Among these conditions, cardiovascular disease (including heart disease and stroke) and cancer are the major causes of mortality. Risks for these diseases exist at each stage of women’s lives, but recognition of the unique needs of women for the prevention and management of NCDs is relatively recent and still emerging.  

Once diagnosed, treatments for these maladies often are costly and noncurative. Hence, there is a call for a strategic, innovative life-course approach to identifying disease triggers and instigating cost-effective measures to minimize exposure in a timely manner. Prohibitive barriers to implementing this holistic effort regarding women’s health exist in both the social arena and the medical arena. Recognizing these impediments and implementing practical approaches to surmounting them is a rational way to advancing health equity for women, with ultimate benefits for society. Although the impact of NCDs is greatest in older women, there is increasing evidence that across all life stages, women are susceptible to risk factors that ultimately contribute to those ailments. The authors contend that early education, timely initiation of preventive measures and consistent risk factor management over the course of a woman’s life represent a strategic approach to prevent or delay the progression of many NCDs. When opportunities for such interventions are overlooked in health systems, there can be substantial socioeconomic implications, as preventive interventions over the life course generally are more cost-effective than treating diseases after onset. 

TREATING PATIENTS WHO KVETCH

Not every day in the life of clinicians is full of joy and self-fulfillment. Apart from stresses and strains associated with providing effective patient care, some individuals on the receiving end of treatment warrant special attention. Welcome to the kvetching arena. The verb kvetch is a Yiddish term defined in the Oxford English Dictionary as “To criticize or complain a great deal.” A paper by Yager and Kay in the January 2024 issue of the Journal of Nervous & Mental Disease indicates that clinicians often encounter patients whose presentations are characterized by long lists of complaints about their biological, psychological, interpersonal, and social conditions. The problems on which complaints are based are variably reality-based and variably modifiable. Some patients display chronic complaining as a core, distinguishing feature. Based on clinical observations enhanced by selective narrative literature review, the authors delineate and differentiate four groups of patients: 1) situational complainers; 2) chronic complainers due to unidentified medical problems; 3) mood-induced chronic complainers; and 4) personality-driven pan-dimensional chronic complainers.  

An example is provided of a perplexing 60-year-old patient who responded to a request for a chief complaint by unleashing a litany of sufferings beginning with a mournful recitation of numerous aches and pains that encompass an area from the top of the head down to the toes. The mix included psychological agonies-anxieties, worries, insomnia, depression, tearfulness, regrets, resentments, grudges, envies, and hurt feelings. Numerous problems were enumerated concerning ungrateful sons, back-biting daughters-in-law who poisoned grandchildren's minds, and a passive-aggressive landlord. The most bitter tirade was reserved for a late spouse who died five years previously, leaving the patient ill-equipped to handle many demands of daily living. All woes were compounded by financial insecurities and frustrations with doctors, pharmacies, and insurance companies. The overall affect varied from bitterness to whimpering to hopeless resignation. Strategies for managing those four groups of patients begin with careful, detailed assessments, including ascertaining reality-based and patient contributions to their complaints. Management approaches that can call upon an array of specific tactics should be formulated according to patient-centered particulars. Sources of countertransference reactions should be identified and addressed. Multiple questions remain and merit further research. 

OBTAINABLE RESOURCES

THE FUTURE OF REMOTE PATIENT MONITORING

Digital health advocates believe remote monitoring, the use of digital technologies to collect and relay patient data to health care professionals, has the potential to transform disease management, health outcomes, and patient care, especially for individuals with multiple chronic conditions who lack convenient access to providers. Medicare, most state Medicaid agencies, and many private health insurance plans cover remote monitoring services. For the purposes of a report from the Bipartisan Policy Center, remote monitoring is defined as an umbrella term for remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM). RPM refers to the monitoring of physiologic data, such as weight, blood glucose, or blood pressure, while RTM refers to the monitoring of patients’ self-reported nonphysiologic data, such as pain levels or medication adherence. Currently, the Centers for Medicare & Medicaid Services (CMS) limits RTM reimbursement to cases involving the respiratory system, musculoskeletal system, and cognitive behavioral therapy. Although the percentage of patients using RPM remains relatively low (594 monthly claims per 100,000 Medicare enrollees in 2021), the use of RPM increased among Medicare beneficiaries more than sixfold from 2018-2021. In part, this increase was due to CMS’ expanded coverage rules during the COVID-19 public health emergency. The  Report looks broadly at ways to improve the use of remote monitoring services, ensure equitable access to these services across populations, and enhance data security and privacy standards. It can be obtained at https://bipartisanpolicy.org/download/?file=/wp-content/uploads/2024/01/BPC_Health_FutureOfRemoteMonitoring.pdf. 

HEALTH CARE WORKERS’ DISCRIMINATION AGAINST PATIENTS 

Discrimination against patients in health care settings on the basis of race, ethnicity, or language can have a negative impact on quality of care and health outcomes. Workers on the front line of care delivery can provide insights about the nature of this discrimination, helping to inform opportunities to address bias and unequal treatment. About half of U.S. health care workers have witnessed racial discrimination against patients and say discrimination against patients is a crisis or major problem, according to a survey released on February 15, 2024 from the Commonwealth Fund and African American Research Collaborative. Six focus groups of health care workers were followed by a survey of 3,000 health care workers across a variety of care settings. Surveyed workers, across all races, ethnicities, ages, genders, and care settings, personally witnessed discrimination against patients and consider it to be a serious problem. Younger health care workers and health care workers of color were more likely than their older or white counterparts to acknowledge witnessing this discrimination. Just under half of all health care workers indicated the discrimination causes them stress. The report is at https://www.commonwealthfund.org/publications/issue-briefs/2024/feb/revealing-disparities-health-care-workers-observations. 

WEARABLE TECHNOLOGIES IN THE WORKPLACE 

A Spotlight released on March 4, 2024 by the Government Accountability Office (GAO ) discusses how companies are deploying technologies worn on the body to try to improve safety and productivity. These items vary in size and function. Technologies such as exoskeletons, which can provide physical support to the user's body during repetitive overhead work, already are used in industrial workplaces. Yet, there are concerns about data privacy, cost, ease of use, and being tracked by the devices. Industrial uses are in four general categories: (1) supporting devices to assist workers with tasks like lifting (e.g., exoskeletons). (2) monitoring devices to alert workers to specific changes in vital signs (e.g., smart helmets); (3) training devices provide feedback on movements to help improve worker performance (e.g., augmented reality glasses); and (4) tracking devices observe the location of employees on a worksite (e.g., GPS trackers). The report is accessible at https://www.gao.gov/assets/d24107303.pdf.

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.