May 18, 2021

IMPACT OF MARRIAGE, DIVORCE, AND WIDOWHOOD ON HEALTH STATUS

May 18, 2021

Marriage, divorce, and widowhood each represent significant events in the lives of anyone who has ever been married, but they especially are prevalent among the older population. Older adults have rich marital histories that reflect both partnership and loss over their lifetime, according to a U.S. Census Bureau report entitled, “Number, Timing, and Duration of Marriages and Divorces: 2016” that became available on April 22, 2021. Divorce is not the only marital disruption that older adults face, however, because they also disproportionately constitute a large percentage of those who become widows or widowers in a given year. Among adults age 15 or older who became widowed in the preceding 12 months, 71% of men and 69% of women were 65 or older, although this age group comprises only 19% of all individuals in the 15 or older age group. Widowhood is particularly common among older women compared to older men due to differences in life expectancies. Women on average live longer than men. Among those 75 years or older who had ever married, 58% of women and 28% of men had experienced the death of a spouse in their lifetime, making this stage of life particularly difficult. The proportion of individuals who currently are widowed is relatively lower than for those widowed at one point because some respondents who lost a spouse eventually remarried, becoming "currently married" instead of "currently widowed." Nonetheless, differences between the sexes persist among those 75 years or older: 54% of women and 20% of men were currently widowed at the time of interview.

Women in particular face major challenges in being able to live with independence and dignity as they age. With longer lives, higher rates of disability and chronic health problems and lower incomes than men on average, many women need long-term care services without having the resources to pay for them. Apart from their own health problems, some women also serve as primary providers of long-term care for an older relative. The vast majority of both paid formal long-term care workers and unpaid informal caregivers are women. Millions of older women cannot afford to pay for long-term care services because of low income. A major factor affecting income is marital status. Married couples have higher incomes than single persons. Older women are much more likely than older men to live alone, meaning that they have no other individual in their household to help with daily activities and pay for services to address unmet health and health-related social needs.

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COGNITIVE EPIDEMIOLOGY, INTELLIGENCE, HEALTH, AND DEATH

Kristen Truong

May 18, 2021

Cognitive epidemiology as a separate line of inquiry emerged in the early 2000s. Its purpose is to study how and why individual differences in intelligence (especially when measured in childhood or young adulthood) associate with later differences in health, illness, and death. An article published in the April 2020 issue of the journal Nature Human Behaviours examines how an understanding of the association between intelligence and health/mortality has been refined with the advent of new, population-scale data and genetic tools. The manuscript looks at the associations between intelligence and, in turn, all-cause mortality, specific causes of mortality, physical illnesses, and health-related biomarkers. Possible causes of the observed associations (education, health behaviors and literacy, and genetics), are not mutually exclusive.

Although the causes underlying the associations between intelligence and health/mortality remain an open question, research over the past decade has provided results and fingerposts for further progress. As a way of obtaining a clearer understanding, the authors discuss how intelligence relates to specific causes of death, diseases/diagnoses, and biomarkers of health through the adult life course. They examine the extent to which mortality and health associations with intelligence might be attributable to differences in education, other indicators of socioeconomic status, health literacy, and adult environments and behaviors. Finally, they discuss whether genetic data provide new tools to understand parts of the intelligence–health associations. Social epidemiologists, differential psychologists and behavioral and statistical geneticists, among others, contribute to cognitive epidemiology. Any advances that occur will do so by building on a common cross-disciplinary knowledge base.

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Kristen Truong

May 18, 2021

Emergency Departments For Bicycle-Related TBIs: United States, 2009-2018

Bicycling leads to the highest number of sport and recreation–related emergency department (ED) visits for traumatic brain injuries (TBIs) in the United States. Because bicycling continues to grow in popularity, primarily among U.S. adults, examining the strategies that mitigate the risk for TBI is important. According to the May 14, 2021 issue of the Morbidity and Mortality Weekly Report, CDC analyzed data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) to determine the incidence of EDs for bicycle-related TBIs during 2009–2018. An estimated 596,972 ED visits for bicycle-related TBIs occurred in the United States during the study period. Rates of ED visits were highest among adult males (aged ≥18 years) and among children and adolescents aged 10–14 years during 2009–2018. Overall, the rate of ED visits for bicycle-related TBIs decreased by approximately one half (48.7%) among children and by 5.5% among adults.

Medicare, Medicaid, Children’s Health Insurance Program Enrollment: 2020

Government involvement in the financing of health care is substantial. According to recent estimated average monthly data from the Centers for Medicare & Medicaid Services, in calendar year 2020: Medicare had a total of 62.8 million enrollees among whom 54.5 million are aged and 7.3 million are disabled. An additional breakdown shows that 37.7 million beneficiaries are enrolled in Original Medicare and the rest are in the Medicare Advantage Plan and the Prescription Drug Plan. Medicaid, a jointly administered federal-state plan, had a total of 76.5 million enrollees in Fiscal Year 2020. Major groups include: 6.4 million aged individuals, 11.0 blind and disabled persons, and 28.9 children—the largest single group numerically. Another 7.4 million individuals are enrolled in the Children’s Health Insurance Program (CHIP) on average each month based on the latest available data.

HEALTH TECHNOLOGY CORNER

Ventilating The Rectum To Support Respiration

The coronavirus pandemic has overwhelmed the clinical need for ventilators and artificial lungs, resulting in a critical shortage of available devices and endangering patients’ lives worldwide. As described in an article published on May 14, 2021 in the journal Med, inspired by organisms such as catfish that use intestinal air breathing, researchers at Tokyo Medical and Dental University show the effectiveness of an enteral ventilation approach in attaining systemic oxygenation in both rodent (e.g., mice) and porcine (e.g., pig) models. Intra-rectal delivery of a liquid form of O2 known as conjugated perfluorocarbon, a compound historically used in clinics for liquid ventilation through airway administration, is highly tolerable and efficacious in ameliorating severe respiratory failure. By repurposing the distal gut as an accessary breathing organ, enteral ventilation therapy offers an alternative paradigm as an adjunctive means to patients who are in critical need of respiratory support.

Opening A Window Into Alzheimer's Disease

According to new research by scientists at the UCSF Weill Institute for Neurosciences, retinal scans can detect key changes in blood vessels that may provide an early sign of Alzheimer's. An article published on May 11, 2021 in the journal Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring offers some important insights into how one of the most common Alzheimer's risk genes contributes to the disease. Researchers have indicated that the most prevalent genetic risk for Alzheimer's disease is a variant of the APOE gene, known as APOE ε4. Although it is not entirely clear how this variant increases risk of brain degeneration, it does appear to do so and the risk is modified by sex, race, and lifestyle. The results of the study reported in this article suggest that APOE ε4 affects capillary health in humans and that retinal capillary measures could serve as surrogates for brain capillaries, providing an opportunity to study microangiopathic contributions to neurodegenerative disorders directly in humans.

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DEVELOPMENTS IN HIGHER EDUCATION

Kristen Truong

May 18, 2021

The arrival of the coronavirus pandemic resulted in college and university campuses having to begin shutting down in March 2020. Many were able to do so without suffering painful losses of valuable forms of income derived from fees associated with tuition, dormitory living, provision of food services, and a variety of activities, such as rental of campus property in the summer and sales of tickets and concessions for football and basketball games. Not every institution was so fortunate, however, and have had to offset reductions in revenue by laying off personnel involved in teaching and administration. Worst of all, some smaller schools without endowments are confronted with the danger of having to close their doors permanently.

One means of offsetting a decline in revenue was to substitute in-class learning with instruction that is provided online. Schools that already offered courses in that manner were able to continue doing so without having to make any major adjustments. Institutions that were not in a similar position had to convert a great many courses that formerly were furnished exclusively in classrooms. Not all students and their families believed that these new products were valuable substitutes and they consequently have been unwilling to pay for them.

Another consideration is more of a downstream nature. Since March 2020, many students throughout the U.S. at elementary and high school levels have not been in classrooms for the latter part of the 2019-2020 academic year and almost all of the 2020-2021 school year. Prior to the pandemic, some students admitted to college typically are academically underprepared and must be provided with remediation services. Students who already were in their third year of high school in spring 2020 are graduating in virtual ceremonies either this month or will do so in June. Many of them may be even less prepared to enroll in college than previous cohorts of students that did so before the pandemic struck the nation.

Student Loan Tax Elimination Act

A chronic problem for many students and their families is mounting educational debt. Individuals at the postgraduate level who attend MBA programs, law chools, and medical schools may assume mountains of such debt, but they are in a favorable and enviable position to move into high paying jobs upon graduation. Less fortunate are those students who complete their formal education at the baccalaureate level with majors that lead to few, low remunerative forms of employment. Even worse off are students who drop out of school without ever completing a degree program, but who still managed to borrow substantial amounts of money for education purposes.

A common aspiration expressed by many Democrat candidates who competed to be nominated by their party for the 2020 presidential election was to address the problem either by forgiving all or a portion of this educational debt. A step in that direction is a bipartisan bill introduced on March 18, 2021 in Congress, the Student Loan Tax Elimination Act (S. 847), a measure designed to eliminate origination fees on all federal direct student loans disbursed on or after March 27, 2020. Presently, by taking as much as 4% of the proceeds of a federal student loan, a strong influence is placed on students regarding their decision whether to pursue and complete a degree program.

Similar legislation was introduced on June 3, 2019. Supporters of the bill view origination fees as reducing the amount of loan dollars disbursed to borrowers by 1% percent for Direct Stafford Loans and 4% for Direct PLUS Loans. This levy is considered to create confusion among students and increase costs for borrowers, who are responsible not only for repaying the withheld amount, but also the interest accruing on that amount. The result can be hundreds or thousands of additional dollars owed, depending on loan type, loan amount, and program length.

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HEALTH REFORM DEVELOPMENTS

Kristen Truong

May 18, 2021

As noted in the Quick STAT page of this issue of the newsletter, in calendar year 2020, the Medicare program had a total of 62.8 million enrollees. As described in an article published on April 27, 2021 in JAMA Network Open, overuse is defined as the delivery of tests and procedures that provide little or no clinical benefit, are unlikely to have an impact on clinician decisions, increase health care spending without improving health outcomes, or risk patient harm in excess of potential bene-fits.Estimates suggest that overuse contributes $75.7 billion to $101.2 billion to wasted U.S. health care spending annually. Results of a cross-sectional study involving 1,325,256 services performed at 3,351 hospitals show that measurements of low-value services using Medicare claims data can be applied to individual hospitals to compare their overall rates of overuse. The analysis revealed differences in overuse by hospital characteristics such as teaching status, region, and nonprofit status. Researchers found that hospitals in the South, for-profit hospitals, and nonteaching hospitals were associated with the highest rates of overuse. Investigations of this nature are critical to developing remedies to curb unnecessary spending. A steady increase in the number of aged beneficiaries who become eligible to participate in the Medicare program means that a corresponding growth will occur in the amount of health services that must be provided for them. Constant efforts are needed to ensure that an ever growing amount of expenditures for such care is used effectively and appropriately. Biden Administration Begins Reversing Policies Established By The Previous AdministrationA common practice in recent years is for an incoming U.S. presidential administration to review health policies instituted by its predecessor administration and decide to reverse them. Along lines of efforts to prevent unnecessary spending in the Medicare program, the Biden administration decided to freeze an effort implemented by the Trump administration to create a new Medicare coverage and reimbursement pathway for “breakthrough” medical devices as its term drew to a close. A final rule known as the Medicare Coverage of Innovative Technology (MCIT) pathway that was published on January 14, 2021 in the Federal Register would have established a mechanism to provide national Medicare coverage for a period of four years after the date of U.S. Food & Drug Administration approval. The final ruling was to become effective on March 1 of this year. An argument opposed to implementing the rule is based on an assessment by the Biden team that the proposed acceleratedpathway fails to protect patients adequately or ensures that such breakthrough devices are effective or appropriate for the Medicare population Another illustration of an attempt to erase policies established by the preceding administration is that the Biden group will enforce legal protections against discrimination for gay and transgender patients seeking health care under the Affordable Care Act (ACA). During the Trump administration, a policy was implemented that aimed to define the scope of sex discrimination under the health law more narrowly than what was prescribed during the Obama Administration. The most recent ruling is based on a Supreme Court decision in 2020 that allows in a more expansive way the U.S. Department of Health & Human Services to interpret the antidiscrimination section of the ACA by forbidding bias “on the basis of race, color, national origin, sex, age or disability.” American Rescue Plan Act And The Affordable Care ActCongress passed the American Rescue Plan Act (ARPA) using what is known as the “budget reconcilia-tion process” that requires only a Senate majority rather than the sixty votes normally needed to over-come a filibuster. President Biden signed it into law on March 11, 2021. The aim of this legislation is to enable a temporary expansion of the ACA’s premium tax credits and to allow increases in federal financial incentives for states that have not yet done so to expand their Medicaid programs to low-income adults. A recent broadened enrollment period has resulted in an increase in the number of beneficiaries wanting to participate in this program. ARPA also provides incentives for the twelve states that have not yet expanded their Medicaid programs to all adults with incomes up to 138% of the federal poverty level.Meanwhile, the fate of the ACA will depend on a decision that soon will be made by the U.S. Supreme Court on a case that has attracted enormous interest in health policy circles.

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A MAJOR FOCUS ON GOVERNMENT SPENDING

Kristen Truong

May 18, 2021

Now that the current fiscal year is going to draw to a close on September 30, greater attention is being paid to Congressional appropriations. The House Appropriations Committee plans to mark up the 12 annual spending bills for fiscal year 2022 in June this year, ahead of floor votes that are scheduled for this July. Recent years have witnessed a failure to complete all necessary business pertaining to appropriations by the coming October 1. If that pattern repeats itself this year, then one or more stopgap spending measures will have to be relied upon as a means of avoiding a federal government shutdown of the federal government.

A new twist in the present arrangement goes to prove that many old and highly cherished notions truly die rather hard. While certain revered ideas can languish for lengthy periods of time, they can reappear with renewed vigor as evidenced by the rebirth of “earmarks,” an excellent illustration of a time-honored approach of dispensing funds appropriated by Congress. Earlier, wags with a penchant for unseasonable japery could hardly wait for former Democrat Senator William Proxmire from Wisconsin to issue his Golden Fleece Award every month between March 1975 and December 1988. The purpose of this dubious honor was to acknowledge “wasteful, ridiculous or ironic use of the taxpayers’ money.” A famous example was a $190 million bridge to a sparsely populated island in Alaska at a cost of $13,786 per local inhabitant.

House Democrats recently unveiled a plan to restore earmarks under the new heading, “Community Project Funding,” thus ending a decade-long policy that forbade the practice. A proposal released by Rosa DeLauro (D-CT), Chairwoman of the House Appropriations Committee, would allow the inclusion of money in annual spending bills to benefit specific projects with the amount capped at 1% of discretionary spending, Lawmakers would be permitted to submit a maximum of 10 project requests, along with evidence to justify their requests from their communities. Funds could not be allocated, however, to benefit for-profit recipients. Joining in this renewal effort, the House Republican Conference has voted to restore earmarks and Senate appropriators also have released their plan to jettison the present ban.

Apart from the important work of introducing and passing necessary legislation, another key function performed on Capitol Hill is to conduct hearings. The Senate Committee on Health, Education Labor & Pensions did so on May 11, 2021. The event on “Efforts to Combat COVID-19” featured testimony by Anthony Fauci, Director, National Institute of Allergy and Infectious Diseases; David Kessler, Chief Science Officer at the U.S. Department of Health and Human Services; Rochelle Walensky, CDC Director; and Peter Marks, Director of the Center for Biologics Evaluation and Research at the Food & Drug Administration. The following day, a hearing on the topic of “COVID-19 Variants and Evolving Research Needs” was held by the Subcommittee on Investigations and Oversight of the House Committee on Science, Space and Technology. Testimony was provided by experts from Columbia University, Yale University, Johns Hopkins University, and the Argonne National Laboratory.

Statements made at both hearings can be obtained from the websites of these committees in print and video formats.

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FUTURE TIME PERSPECTIVE IN MID–TO-LATER LIFE

Kristen Truong

March 22, 2021

Future time perspective (FTP), or the way individuals orient to and consider their futures, is considered fundamental to motivation and well-being. Given FTP’s relevance to healthy adaptation, recent work has described its contributing factors, especially age, health, and personality. Yet, the extant literature is plagued by inconsistent FTP conceptualizations and sample characteristics. Specifically, although relationships between FTP and its contributors seem dependent on both FTP conceptualization and sample life-span stage, much existing literature emphasizes differing FTP conceptualizations and young adult samples, complicating cross-study conclusions. As reported in the March 2021 issue of The Journals of Gerontology: Series B, Psychological Sciences and Social Sciences, a study was conducted that explored the ways in which age, health, and personality simultaneously contribute to FTP in mid-to-later life with machine-learning techniques.

Until now, no studies regarding how these factors jointly contribute to FTP have been conducted and it is unclear as to whether complex interactions exist among these predictors in their relation to FTP. Personality, especially neuroticism, extraversion, conscientiousness, and agreeableness, had the most influence on FTP. Age and health were not among the most salient FTP contributors in mid-to-later life. Furthermore, decision tree analyses uncovered interactive effects of personality. Several profiles of neuroticism, extraversion, and conscientiousness were linked with differing FTP levels. Although current literature has indicated that FTP, age, and health are inextricably tied, these results indicate that there is more variability to be explained in FTP, perhaps especially when looking within specific age groups.

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EMERGING CLINICAL ROLE OF WEARABLES

Kristen Truong

March 22, 2021

Wearable technology, also known as “wearable devices” or simply “wearables,” generally refers to any miniaturized electronic device that easily can be donned on and off the body, or incorporated into clothing or other body-worn accessories. While wearables have established utility in the fitness, gaming, and entertainment industries, their role in the healthcare environment remains less clear. According to a manuscript published on March 10, 2021 online in the journal npj Digital Medicine, to date most commercially available wearables are limited in scope, tracking one or two health-related variables, and have yet to produce accurate measurement of many markers of health status that they attempt to assess such as heart rate variability, nutrition, and mood. To the extent that wearables overcome these limitations, they hold much promise towards expanding the clinical repertoire of patient-specific measures. They are considered an important tool for the future of precision health. For example, physical activity is a well-established marker of current health status and future health risks, it is a useful estimate of real-life functional performance, and it has been tracked in health research using body-worn sensors for many decades. Given the ubiquity of physical activity monitors, it is surprising their effective incorporation into clinical care remains a challenge, especially in face of the multiple known health benefits of physical activity and the many healthcare scenarios where physical activity information has a clinical use.

Two of the NIH’s Big Data to Knowledge Centers of Excellence organized a workshop on potential clinical applications of wearables to address various challenges. A workgroup from diverse backgrounds (hospital administration, clinical medicine, academia, insurance, and the commercial device industry) discussed two successful digital health interventions that involve wearables to identify common features responsible for their success. Seven features were identified including: a clearly defined problem, integration into a system of healthcare delivery, technology support, personalized experience, focus on end-user experience, alignment with reimbursement models, and inclusion of clinician champions. For each feature, problems are outlined within the patient domain that are addressed per feature and specific representative examples of solutions are provided for these problems by the two sample digital health programs. Health providers and systems eager to establish new models of care inclusive of wearables may consider these features during program design. A better understanding of these features is necessary to guide future clinical applications of wearable technology.

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OBTAINABLE RESOURCES

Kristen Truong

March 22, 2021

Academic Incentives And Research Impact

The road to tenure can be viewed as paved with measures of peer-reviewed publications, first authorships, citations, journal impact, grant funding, and national or international reputation. According to the author of a paper that was prepared for the organization AcademyHealth, a proposition is offered that for the most part, measures of research impact on societal problems are missing in action from performance evaluation criteria within academic disciplines. So, the paper aims to encourage creative thinking around academic incentives and research impact by challenging existing orthodoxies, generating new insights, and stimulating a productive debate within the discipline. As a means of accomplishing these objectives, cases are presented to explore efforts challenging the status quo of academic research incentives and realigning them to focus more on societal impact. The cases are organized around a system-, institutional-, and individual-level framework. Examples are furnished that highlight the range of efforts explored more fully in the paper to align academic incentives with societal impact. The paper can be obtained here.

Student Debt And Its Impact On Black Americans

As more students take out more loans at higher amounts, the issue of student debt and proposals to mitigate it has taken greater prominence in national policy debates. According to a report from the Brookings Institution, the problem especially is pertinent for Black households, for whom a lack of generational wealth risks making student debt a long-term financial burden. After graduation, loans quickly balloon, delaying or even preventing Black Americans from building wealth. Based on the 2018 Survey of Income and Program Participation (SIPP), the authors indicate that because student debt disproportionately harms the wealth-poor, and the Black wealth-poor in particular, student debt cancellation could be a powerful tool in dismantling institutional discrimination and shrinking racial wealth disparities if implemented correctly. They center the Black experience in their consideration of student loan debt and draw from their own analysis to argue for debt cancellation that is not means-tested (predicated upon household income) as an important mechanism for closing the racial wealth gap. They compare the effects of cancelling debt against the status quo, and at three different levels of intervention: 1) $10,000 cancelled for all (as President Joe Biden has proposed); 2) up to $50,000 cancelled based on means-testing for households earning under $100,000 and a sliding scale cancellation for households earning up to $250,000 (as Senator Elizabeth Warren [D-MA] has proposed); and 3) total debt cancellation (as Senator Bernie Sanders [I-Vt.] has proposed). They find that the more student debt that is cancelled, the greater the effect increasing Black wealth, particularly for households below the wealth median. The report can be obtained here.

Adult Family Care As An Alternative To Nursing Homes

A report from AARP that was written for consumers, advocates, and state policy staff, summarizes some key features of Adult Family Care (AFC), along with ideas for expanding its availability. Individuals who need long-term services and supports want alternatives to nursing homes as living options. AFC, which is not as well known among consumers as home care and assisted living, gives older adults and persons with disabilities a viable alternative. In AFC, sometimes called adult foster care or adult family homes, residents live full-time in a house or other small residential setting where they receive assistance with activities of daily living, personal care, and help with medications and other health care tasks, in collaboration with health care professionals. More than 40 years ago, Oregon and Washington were the first states to establish AFCs as an option for both private pay residents and those receiving public funds. Many jurisdictions have had difficulty recruiting providers and consumers since then. The report can be obtained here.

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Kristen Truong

March 22, 2021

U.S. State Life Tables, 2018

A new report from the National Center for Health Statistics presents the first set of annual complete period life tables for each of the 50 states and the District of Columbia (D.C.) for the year 2018. The period life table does not represent the mortality experience of an actual birth cohort. Rather, it presents what would happen to a hypothetical cohort if it experienced throughout its entire life the mortality conditions of a particular period in time. Life tables were produced for the total, male, and female populations of each state and D.C. based on age-specific death rates for that year. Among the 50 states and the District of Columbia, Hawaii had the highest life expectancy at birth, 81.0 years in 2018, and West Virginia had the lowest, 74.4 years. Life expectancy at age 65 ranged from 17.5 years in Kentucky to 21.1 years in Hawaii. Life expectancy at birth was higher for females in all states and D.C. The difference in life expectancy between females and males ranged from 3.8 years in Utah to 6.2 years in New Mexico.

Prescription Drugs For Older Adults And The Risk Of Falling

Published on February 3, 2021 in Pharmacoepidemiology and Drug Safety, a study reported from the University at Buffalo examined data on deaths due to falls and prescription fills among patients 65 and older from the National Vital Statistics System and the Medical Expenditure Panel Survey. Age-adjusted mortality due to falls increased from 29.40 per 100,000 in 1999 to 63.27 per 100,000 in 2017. The percent of individuals who received at least one prescription for a fall risk increasing drug, including antidepressants, anticonvulsants, antipsychotics, antihypertensives (for high blood pressure), opioids, sedative hypnotics, and benzodiazepines (tranquilizers such as Valium and Xanax) increased from 57% in 1999 to 94% in 2017. Fall risk increasing drugs may partially explain the increase in mortality due to falls, but cannot be firmly concluded from the current study. Future research involving nationally representative person‐level data are needed.

HEALTH TECHNOLOGY CORNER

Sex Differences In Neurodegenerative Diseases

Many neurodegenerative diseases, including Alzheimer's disease, Parkinson's disease, multiple sclerosis, and motor neuron disease, demonstrate clear sexual dimorphisms. While sex as a biological variable must now be included in animal studies, sex rarely is included in in vitro models of human neurodegenerative disease. A review published on March 16, 2021 online in APL Bioengineering describes these sex-related differences in neurodegenerative diseases and the blood–brain barrier (BBB), whose dysfunction is linked to neurodegenerative disease development and progression. The authors from the University of Maryland highlight a growing body of research suggesting sex differences play roles in how patients respond to these ailments. The authors note that some research suggests the barrier can be stronger in women than men, and the barriers in men and women are built and behave differently. They hope their article will serve as a reminder across the sciences, that accounting for sex differences leads to better results.

Female College Athletes And Traumatic Brain Injury

Female athletes are under-studied in the field of concussion research, despite evidence of higher injury prevalence and longer recovery time. Hormonal fluctuations caused by the natural menstrual cycle (MC) or hormonal contraceptive (HC) use have an impact on both post-injury symptoms and neuroimaging findings, but the relationships among hormone, symptoms, and brain-based measures have not been jointly considered in concussion studies. A preliminary investigation from the Northwestern University Feinberg School of Medicine published on February 24, 2021 in the Journal of Neurotrauma compared cerebral blood flow (CBF) measured with arterial spin labeling between concussed female club athletes 3–10 days after mild traumatic brain injury (mTBI) and demographic, HC/MC matched controls (CON). Researchers tested whether CBF statistically mediates the relationship between progesterone serum levels and post-injury symptoms, which may support a hypothesis for that hormone's role in neuroprotection. The findings support a hypothesis for its having a neuroprotective role after concussion and highlight the importance of controlling for the effects of sex hormones in future concussion studies.

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DEVELOPMENTS IN HIGHER EDUCATION

Kristen Truong

March 22, 2021

Another section of this newsletter indicates that the $1.9 trillion COVID-19 relief legislation called the American Rescue Plan Act (P.L. 117-2) was signed into law by President Joe Biden on March 11, 2021. One of its provisions is Section 2003, Higher Education Emergency Relief Fund. The amount of $39,584,570,000 will be made available through September 30, 2023, for making allocations for colleges and college students. Institutions receiving aid must dedicate at least half of the funding for emergency financial aid grants to prevent hunger, homelessness, and other hardships that students are facing because of the pandemic. Funds also can be used for general expenditures for institutions of higher education to cover those expenses associated with a disruption in services or operations related to coronavirus, including defraying expenses caused by lost revenue and reimbursing expenses already incurred.

The public health workforce consists of a great many different kinds of health professionals. Section 2501, Funding For Public Health Workforce will furnish $7,660,000,000, to remain available until expended, to carry out activities related to establishing, expanding, and sustaining a public health workforce, including by making awards to State, local, and territorial public health departments. The money shall be used for costs, including wages and benefits, related to the recruiting, hiring, and training of individuals to serve as case investigators, contact tracers, social support specialists, community health workers, public health nurses, disease intervention specialists, epidemiologists, program managers, laboratory personnel, informaticians, communication and policy experts, and any other positions as may be required to prevent, prepare for, and respond to COVID–19. This financial support is aimed at personnel who are employed by governmental public health departments and nonprofit private or public organizations with demonstrated expertise in implementing public health programs, particularly in medically underserved areas.

Counting U.S. Postsecondary And Secondary Credentials

The organization Credential Engine since 2017 has been engaged in laying bare an increasingly complex and confusing landscape of U.S. credentials, and to create the building blocks to make reliable and useful credential information more accessible for students, workers, and the employers who hire them. Part of the effort has consisted in creating a common taxonomy, or schema, through the Credential Transparency Description Language (CTDL) that allows individuals to make “apples-to-apples” comparisons between and among credentials, making it possible to map connecting points between credentials, competencies, jobs, education, and training opportunities. The driving force has been a lack of clarity about what exactly is available in education and training, the value of credentials in the labor market, and what enables certain individuals to benefit from those opportunities more than others. The CTDL is regarded as the standard language through which these million unique credentials and their competencies can be connected, compared, and contrasted, from evaluating whether a credential leads to a specific career and higher wages or if it leads to a higher-level credential, enhancing economic momentum and mobility.

Some Impacts Of COVID-19 On Higher Education

New international student enrollment in the United States and online outside the United States decreased by 43% in Fall 2020. Many international students studying at U.S. institutions took advantage of opportunities to begin their studies remotely. Ninety percent of institutions reported international student deferrals in Fall 2020. Respondents indicated that nearly 40,000 students had deferred enrollment to a future term. (Source: Institute of International Education)
The drop in the number of undergraduates enrolled in the fall of 2020 was 3.6% or a decrease of 360,000 students from a year earlier. (Source: National Student Clearinghouse Research Center)
Colleges and universities closed out 2020 with continued job losses, resulting in a 13% drop of 650,000 workers since February of that year. (Source: Bureau of Labor Statistics)

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HEALTH REFORM DEVELOPMENTS

Kristen Truong

March 22, 2021

Congress represents a fascinating portion of American life. Elected officials in both chambers find themselves on every major issue needing to decide whether their vote will advance the interests of their supporters in congressional districts and states back home, who made it possible for them to be elected, or have it enhance the welfare of the nation as a whole. Conflicts of this nature arise all the time. For example, improving the environment would seem to be a goal with widespread appeal, but if it means seriously damaging the fossil fuel industry in a state that is heavily dependent on jobs and revenues from oil, coal, and gas economic activities, it becomes less easy for officials from there to cast votes that favor the nation over the locale. Doing so usually will result in a rapid, undesired exit from political office following the next election.

Despite several decades of efforts on Capitol Hill to ensure that all inhabitants of the U.S. have adequate health insurance coverage, many individuals continue to lack that form of protection. Congress is balanced evenly in the number of Democrats and Republicans in the Senate while the House tilts slightly in favor of the Democrats numerically. As reported on March 5, 2021 in the New England Journal of Medicine, on the issue of universal health insurance coverage, the two parties’ constituents appear to be sharply divided. Nearly nine in 10 Democrats (87%) reported that they believe it is the responsibility of the government to ensure all individuals in the U.S. have health insurance coverage, a view shared by fewer than one in four Republicans (23%). Among Democrats, 75% reported that they prefer a health insurance system mostly run by the government, whereas 79% of Republicans reported that they prefer a system based mostly on private health insurance.

Regarding specific coverage proposals, Democrats expressed support for the following: building on the Affordable Care Act (ACA) [93%], Medicare-for-All (85%), and a Medicare buy-in to the ACA referred to as “the public option” (82%). In contrast, only 30% of Republicans expressed support for building on the ACA and 28% supported Medicare-for-All. While 62% of Republicans reported that they support a Medicare buy-in to the ACA, that support does not represent an endorsement of the notion that government should ensure universal coverage. Also, 64% of Republicans reported that they support replacing the ACA with a state-based private health insurance alternative compared with 36% of Democrats. These substantial differences do not bode well for implementing major changes any time soon in how health insurance is provided in this nation.

Medicare Payment Advisory Commission (MedPAC)

Apart from highly trained staff members in Congress, elected officials often profit from advice provided by other sources, one of which is MedPAC. The Commission is an independent congressional agency established by the Balanced Budget Act of 1997 (P.L. 105–33) to advise the Congress on issues affecting the Medicare program. Besides advising that body on payments to health plans participating in the Medicare Advantage program and providers in Medicare’s traditional fee-for-service program, MedPAC has additional responsibilities that involve analyzing access to care, quality of care, and other issues affecting the Medicare program. Its 17 members can seek to influence the work of Congress in several ways, one of which is the issuance of reports in March and June each year that contain various Commission recommendations.

The report sent on March 15, 2021 consists of 14 chapters that deal with such matters as: the near-term consequences of the coronavirus pandemic and the longer-term effects of Medicare spending on the federal budget and the program’s financial sustainability, and an option for Medicare’s coverage of telehealth services after the coronavirus public health emergency. Both the short- and long-term contexts for the Medicare program are sobering. Because of the pandemic, in the short term, beneficiaries are at particular risk. Patients over 65 are more likely to suffer severe COVID-19 cases and complications and die than those who are younger and have fewer comorbidities. Long-term, the financial future of the Medicare program was already problematic, but as a result of job losses, in 2020 the Congressional Budget Office projected that Medicare’s Hospital Insurance Trust Fund will become insolvent by 2024, two years earlier than previously expected.

return to March 2021 trends

AMERICAN RESCUE PLAN BECOMES LAW

Kristen Truong

March 22, 2021

The American Rescue Plan Act (P.L. 117-2) was signed into law by President Joe Biden on March 11, 2021. A $1.9 trillion COVID-19 relief package, a final version of this legislation (H.R. 1319) was passed by the House of Representatives on a 220-211 vote on March 10 after the Senate voted 50-49 to amend the House’s initial version on March 6. No Republicans supported the legislation. Representative Jared Golden (D-ME) was the only Democrat to oppose it. A 1,149-page House Report of the Committee on the Budget, together with Minority Views, accompanied H.R. 1319. Among the key provisions of this law are the following in rounded numbers:

$48 billion for COVID-19 testing and tracing
$7.5 billion for the Centers for Disease Control and Prevention’s (CDC) vaccine distribution effort
$1.75 billion for the CDC to increase genome sequencing of SARS-CoV-2 for variant surveillance
$7.7 billion in awards under the Department of Health and Human Services to state, local, and territorial health departments to establish, expand, and sustain the public health workforce
$140 million in a one-time supplemental appropriation for HRSA training programs to address and prevent suicide, burnout, mental health conditions, and substance use disorders affecting the health workforce
$40 billion for the Higher Education Emergency Relief Fund

The bill also expands access to health care by providing tax subsidies to a wider range of individuals and families who purchase health insurance on the markets established under the Affordable Care Act (ACA). Additionally, P.L. 117-2 temporarily covers the entire cost of COBRA premiums for individuals who lose their jobs and incentivizes additional states to expand Medicaid as allowed under the ACA.

According to a report issued by the Congressional Budget Office (CBO) in March 2021, by the end of fiscal year 2021 on September 30, federal debt held by the public is projected to equal 102% of gross domestic product (GDP). If current laws governing taxes and spending generally remain unchanged, debt would equal 107% of GDP in 2031, its highest level in the nation’s history. Growth in outlays would outpace growth in revenues in subsequent decades, leading to growing budget deficits over the long term. As a result, federal debt would continue to increase, exceeding 200% of GDP by 2051.

Eventually, the federal government will have to create a means of paying for benefits flowing from the American Rescue Plan Act, along with pandemic-related expenditures from legislation enacted in 2020. Three ways of doing so are to: increase borrowing, raise taxes, and reduce other kinds of federal spending. Both near and distant future actions by Congress will determine what steps will be taken.

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HEALTH CARE COMPLEXITY AND UNCERTAINTY

Kristen Truong

March 22, 2021

Two distinguishing characteristics of the health care sphere are complexity and uncertainty. Last month’s issue of this newsletter contained a discussion of a term known as the prodrome, a period in biomedical research wherein an individual experiences some symptoms of an illness before meeting formal diagnostic criteria. It ends once a patient meets such criteria and is diagnosed with a disorder. Diagnostic standards are consequential. Not only can they label and stigmatize, they have the power to confer or deny access to social resources. Related features include fluidity and malleability, with the boundaries between health and illness subject to redefinition and reorganization.

Neuroscientific research suggests the presence of prodromal phases for a growing list of conditions, including schizophrenia and autism. Another example of possible complexity and uncertainty is schizoaffective disorder (SAD), a controversial diagnosis. Debate continues over its conceptualization, with some experts viewing SAD as an independent disorder, while others see it as either a form of schizophrenia or a mood disorder. If the focus is on an episode (DSM-IV, Diagnostic and Statistical Manual of Mental Disorders) rather than on the longitudinal course of the illness (DSM-V), this difference likely could lead to changed rates of diagnosis of SAD, but controversy remains over classification.

A paper appearing on February 16 of this year in the journal Theoretical Medicine and Bioethics indicates that which concept of disease is assumed has implications for what conditions count as diseases and, by extension, who may be regarded as having a disease (disease judgements) and who may be accorded the social privileges and personal responsibilities associated with being sick (sickness judgements). The authors consider an ideal diagnostic test for coronavirus disease (COVID-19) infection regarding four groups of individuals: (1) positive and asymptomatic, (2) positive and symptomatic, (3) negative, and (4) untested, showing how different concepts of disease have an impact on the disease and sickness judgements for these groups.

The third edition of the DSM in 1981 contained a definition of mental disorder that included a harm requirement (necessitating distress or disability to the individual) so that homosexuality could be coherently eliminated from the catalogue of diseases. This move changed the applicability of what is called disease judgement. Given that homosexuality does not cause harm and is therefore not a disease, according to the current definition of mental disorder, individuals who are homosexual cannot be regarded as having a disease. Concepts of disease also have implications for what are called sickness judgements about how the rights and restrictions associated with forms of sickness are attributed to individuals by virtue of their condition (e.g., entitlement to treatment and reimbursements, or the obligation to surrender one’s driving license). Sickness is the social aspect of disease. While disease and sickness judgements do not always correspond, the concept of disease places constraints on what counts as sickness. Thus, attainment of greater clarity among these concepts has the potential to improve clinical care.

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IMPLICATIONS OF GENETIC TESTING FOR SUICIDE RISK

Kristen Truong

February 22, 2021

The article on page one of this issue of TRENDS has a reference to how research soon may allow calculation of polygenic risk scores (PRS) for suicide death. Data reported in a study in the February 2021 issue of the journal Nature Genetic Medicine indicate that suicide claims the lives of over 47,000 individuals annually in the U.S. and the national rate has increased by 33% between 1999 and 2017. Genetic factors are viewed as playing a major role in suicide risk, with an estimated heritability of close to 50% for suicide death and as much as 30% for suicide attempt. Research during the past decade has begun to characterize genetic variation associated with suicide and suicide attempts. Notably, this genetic risk seems independent of variants associated with developing depression or other mental illnesses. Similar to other psychiatric genetic research, suicide research has not yet identified well-replicated genes and gene pathways leading to functional mechanisms, but increasing momentum and support for large-scale research suggests that investigators rapidly are approaching this goal.

Even before specific risk genes and pathways are discovered, studies of suicide risk may allow the calculation of polygenic risk scores for suicidality. Once these data are available, they may rapidly be commercialized and marketed to the public as direct-to-consumer testing that currently is not subject to extensive regulation. Given these rapid developments, there is an urgency to understanding how individuals may interpret and act on this information. The aforementioned journal article reports the results of initial focus group research related to knowledge about and perceived acceptability of genetic testing for suicide risk among suicide attempt survivors and family members of individuals who died of suicide. The findings from the study highlight the importance of extensive engagement with potential stakeholders before such genetic technologies are made available for clinical or public use.

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THE PRODOME: DIAGNOSIS, DISADVANTAGE, AND BIOMEDICAL AMBIGUITY

Kristen Truong

February 22, 2021

According to an article published in the March 2021 issue of the journal Society and Mental Health, diagnostic standards are consequential, as diagnoses can label and stigmatize, while conferring or denying access to social resources. Diagnostic criteria also are fluid and malleable, with the boundaries between health and illness subject to redefinition and reorganization. Technology may be an engine driving such redefinition of diagnoses. Viewed from that perspective, science and technology can create, reveal, or redefine disorders, making some diagnoses possible while hindering others. In this article, the author engages with the intersection of science and diagnosis by demonstrating how the prodrome, an emerging phase of illness characterized by neuroscientific research, creates problems for patients, their families, and health care institutions. In biomedical research, the prodrome is a period wherein someone experiences some symptoms of an illness before meeting formal diagnostic criteria. The prodrome ends once a patient meets formal criteria and is diagnosed with a disorder. It is of biomedical interest because these symptoms might provide advanced notice of impending illness.

The focus of this particular article is on Huntington Disease (HD), while acknowledging that neuroscientific research suggests the presence of prodromal phases for a growing list of conditions, including schizophrenia and autism. In this instance, the prodrome is examined from the standpoint of its social, experiential, and institutional consequences. Based on interviews with individuals and their informal caregivers, an explanation is provided regarding how the prodrome is a site of healthcare disadvantage. Although participants suffer from psychiatric and cognitive prodromal symptoms (e.g., hallucinations, mood changes) and associated challenges (e.g., job loss), they do not receive necessary support because they do not meet formal diagnostic criteria. The prodrome is viewed as being connected to: (1) the inability to access health care, (2) the inability to access health resources, (3) the depletion of personal resources, and (4) extensive caregiver burden and burnout. The HD prodrome also provides a contrast to research on the negative repercussions of diagnostic expansion, as prodromal individuals report struggling with symptoms that are well-characterized in neuroscientific research, but remain unacknowledged and under supported by health care institutions. An argument is advanced that prodromal individuals are shut out of health services as a result of such institutional ambiguities.

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OBTAINABLE RESOURCES

Kristen Truong

February 22, 2021

Voluntary Support Of Education

Since 1957, the Voluntary Support of Education (VSE) annual survey from the Council for Advancement and Support of Education (CASE) has collected data on fundraising outcomes in higher education institutions in the United States. It is regarded as the definitive source of information on philanthropic support of those institutions. Data from the survey are used to estimate total charitable support of all institutions of higher education in the nation, including nonrespondents. Survey respondents must adhere to the Reporting Standards and Management Guidelines, first published jointly with the National Association of College and University Business Officers (NACUBO) in 1982. CASE updated the standards in 1996, 2004, and 2009. According to the VSE survey, voluntary support of higher education institutions in the United States essentially was flat in the fiscal year that, for most institutions, ended June 30, 2020. While support edged down two-tenths of a percent, at $49.50 billion, nearly half, 48.6%, of responding institutions reported that giving rose in 2020. A CASE analysis of institutions that responded for the past four reporting cycles reveals that varying frequencies of rising and falling gift receipts are the norm. Indeed, even an institution that posts lower levels of giving in a particular year may have had a good year. Sometimes a very large gift the previous year results in a percentage decline that is not really a negative event. The report can be obtained here.

National Healthcare Quality And Disparities Report

The National Healthcare Quality And Disparities Report Chartbook On Patient Safety is the product of collaboration among agencies across the U.S. Department of Health and Human Services (HHS). It is part of a family of documents and tools that support the National Healthcare Quality and Disparities Report (NHQDR). The NHQDR is an annual document to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). The NHQDR provides a comprehensive overview of the quality of health care received by the general U.S. population and disparities in care experienced by different racial and socioeconomic groups. The purpose of the reports is to assess the performance of the U.S. health care system and to identify areas of strengths and weaknesses along three main axes: access to health care, quality of health care, and NHQDR priorities. The reports are based on more than 250 measures of quality and disparities covering a broad array of health care services and settings. Data generally cover 2000 through 2018. The reports are produced with the help of a Federal Interagency Work Group led by the Agency for Healthcare Research and Quality (AHRQ) and submitted on behalf of the Secretary of the U.S. Department of Health and Human Services (HHS). Chartbooks are organized around six Priority Areas. Patient Safety is one of them. They are interrelated and work to support all priority areas and can support necessary and critical improvements in making care safer. The Chartbook can be obtained here.

50-State Survey Of Telehealth Commercial Insurance Laws

States are stepping up requirements that insurers pay for telehealth at the same rate as in-person services, according to a new report from Foley and Lardner. Four more states required payment parity amid the pandemic last year, bringing the total to 14 states. The law firm argues that without such laws, insurers might set reimbursement rates so low that health providers feel no incentive to adopt telehealth. State-mandated coverage of text messages, images, and other “asynchronous health care” also has grown, with 27 now requiring reimbursement. Telehealth has skyrocketed, driven by patient concerns about contracting the virus during in-person visits to clinics or doctors’ offices. What remains unknown is whether Congress and the Biden Administration will make permanent some of the temporary federal payment policies set for the pandemic once it subsides. The report can be obtained here.

return to February 2021 trends

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Kristen Truong

February 22, 2021

Sexual Orientation Disparities In Risk Factors For Adverse COVID-19–Related Outcomes

Sexual minority individuals experience health disparities associated with sexual stigma and discrimination. Lesbian, gay, and bisexual persons in the U.S. have higher self-reported prevalence of several underlying health conditions associated with severe COVID-19 outcomes, compared to heterosexual persons, according to the February 5, 2021 issue of Morbidity and Mortality Weekly Reports. Between 2017 and 2019, sexual minorities, whether part of the overall population or among racial and ethnic minority groups, reported higher rates of asthma, chronic obstructive pulmonary disease, stroke, kidney disease, cancer and heart disease. Based on these findings, CDC indicated that including information on sexual orientation and gender identity, along with race and ethnicity, in COVID-19 data collections could improve knowledge about disparities in these communities. Current surveillance systems lack information on sexual orientation, hampering examination of COVID-19–associated disparities among sexual minority adults.

Instant Death More Common In Absence Of Physical Exercise

Heart disease is the leading cause of death globally and prevention is a major public health priority. Until recently, an aspect involving little information has been the effect of an active versus sedentary lifestyle on the immediate course of a heart attack. Now, there is evidence that an active lifestyle is linked with a lower chance of dying immediately from a heart attack based on a study published on February 12, 2021 in the European Journal of Preventive Cardiology. Researchers used data from 10 European observational cohorts including healthy participants with a baseline assessment of physical activity who had a heart attack during follow-up, a total of 28,140 individuals. While 17.7% died within 28 days of their heart attack, 62.3% of them died instantly. Patients who had engaged in moderate and high levels of leisure-time physical activity had a 33% and 45% lower risk of instant death compared to sedentary individuals. These numbers were 36% and 28%, respectively at 28 days.

HEALTH TECHNOLOGY CORNER

Identifying Candidates For Drug Repurposing For SARS-CoV-2

When COVID-19 arrived, researchers began seeking effective treatments, but producing new drugs can be a lengthy process. The only expedient option may be to repurpose existing medications. As reported on February 15, 2021 in the journal Nature Communications, a team from MIT's Department of Electrical Engineering and Computer Science, the Institute for Data, Systems and Society, and the Broad Institute of MIT and Harvard developed a machine learning-based approach to identify drugs already on the market that potentially could be repurposed to fight COVID-19, particularly in the elderly. Given that SARS-CoV-2 pathogenicity is highly age-dependent, it is critical to integrate aging signatures into drug discovery platforms. To identify robust druggable protein targets, researchers propose a principled causal framework that makes use of multiple data modalities. The investigators pinpointed the protein RIPK1 as a promising target for COVID-19 drugs, and they identified three approved drugs that act on the expression of RIPK1.

Affordable CRISPR App Reveals Unintended Mutations At Site Of CRISPR Gene Repair

Scientists have developed an affordable, downloadable app that scans for potential unintended mistakes when CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats) is used to repair mutations that cause disease. During CRISPR-directed gene editing, multiple gene repair mechanisms interact to produce a wide and largely unpredictable variety of sequence changes across an edited population of cells. Shortcomings inherent to previously available proposal-based insertion and deletion (indel) analysis software necessitated the development of a more comprehensive tool that could detect a larger range and variety of indels while maintaining the ease of use of tools currently available. As reported on February 10, 2021 in The CRISPR Journal, researchers developed Deconvolution of Complex DNA Repair (DECODR) to determine the identities and positions of inserted and deleted bases in DNA extracts from both clonally expanded and bulk cell populations. The software is accurate in making these determinations.

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HEALTH REFORM DEVELOPMENTS

Kristen Truong

February 22, 2021

During the early days of cinematography, it was common for the lights in a movie theater to be turned on as an employee mounted the stage to make the following announcement, “One minute please while we change reels.” Federal health policy in the United States often is implemented in a similar manner. Regardless of the many alterations made during any presidential administration, as soon as a new president arrives on the scene from the opposing political party, several items are at a high risk of being reversed. Some examples of changes that have been made by the Biden Administration are as follows:

The regular Affordable Care Act sign-up period ended on December 15, but President Biden signed an executive order launching a special 90-day enrollment period for ACA coverage, which began on February 15. The Administration seeks to increase public awareness of the extended timeframe through a $50 million marketing campaign.

An executive order directs the U.S. Department of Health and Human Services (HHS) to review the interoperability of public health data systems across the nation. The objective is to improve COVID data sharing throughout the federal government, enhance vaccine distribution, and increase the understanding of the scope of the pandemic in communities throughout the country.

The following rules proposed by the Centers for Medicare and Medicaid Services (CMS) during the Trump administration have been withdrawn: Conditions for Coverage for End-Stage Renal Disease Facilities—Third Party Payments; Strengthening Oversight of Accrediting Organizations (AO) and Preventing AO Conflict of Interest, and Related Provisions; and Revisions to Medicare Part A Enrollments.

Unwinding Medicaid Work Requirements

The Biden Administration has expressed strong interest in beginning the process of rolling back Medicaid work requirements, an initiative developed when President Trump was in office, which generally mandated that beneficiaries log 20 or more hours on a job, look for work, perform community service, or take educational classes to be eligible for Medicaid benefits. Kentucky, Arkansas, and Nebraska are among 12 states that received federal approval to impose such requirements, although some plans were blocked by the courts. A possibility remains that some states may elect to challenge these roll back efforts.

Concentration Of Health Care Expenditures

A significant portion of health legislation is aimed at controlling health care costs. In the newest Statistical Brief, data from the Agency for Healthcare Research and Quality (AHRQ) Medical Expenditure Panel Survey Household Component (MEPS-HC) describe the overall concentration of health care expenses across the U.S. civilian noninstitutionalized population in 2018. Spending on health care that year accounted for 17.7% of the U.S. gross domestic product, yet the majority of this spending was concentrated in a small percentage of the population. Older individuals disproportionately were represented in the higher healthcare spending tiers. Among the entire U.S. civilian noninstitutionalized population in 2018, 16.8% were 65 and older, while 22.6% were under age 18. Among the top 5% of spenders, however, 39.0% were 65 and older, while only 5.8% were children under age 18. In contrast, among the bottom 50% of spenders, 30.6% were children while only 6.0% were 65 years and older.

Steady growth in the portion of individuals age 65 and older in the population will have an impact on efforts to lower health care spending due to the amount of money that will be spent on addressing their health care needs. The most commonly treated condition among the top 5% percent of spenders in 2018 was hypertension (48.8%), followed by osteoarthritis/other non-traumatic joint disorders (44%), and nervous system disorders (40.0%). While these conditions are the most common among high spenders, they are not necessarily the most expensive ones to treat. Instead, the top spending group is more likely to include patients with multiple chronic conditions or expensive treatments (e.g., surgeries, and hospitalizations) related to these conditions.

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AMERICAN RESCUE PLAN AND COVID-19

Kristen Truong

February 22, 2021

The new Biden Administration arrived in the nation’s capital with ambitious plans to work cooperatively with Congress in dealing with the many problems associated with the coronavirus pandemic. The president’s American Rescue Plan is a centerpiece of that effort. Major committees on Capitol Hill have responded positively and have begun to set in motion legislation to achieve several important objectives aimed at combining individual bills into a $1.9 trillion COVID-19 relief package, which the House Budget Committee “marked up” and passed today, combining the individual Committee proposals into a single reconciliation bill that will be taken up on the House floor at the end of the week, with enactment expected in mid-March.

As described in the previous issue of this newsletter, reconciliation legislation is a fast-track process that can be passed by a simple majority without having to be filibustered in the Senate. Some limitations exist in this approach because budget reconciliation cannot be used for any and all federal legislation. Instead, bills must contain provisions that affect revenue and spending, with no extraneous items allowed, according to a restriction known as the “Byrd Rule.”

The House Education and Labor Committee’s portion of the reconciliation bill provides $170 billion to K-12 and postsecondary education, with $40 billion dedicated to higher education to make necessary COVID related improvements on campus and provide additional student supports. Funding will be provided to institutions via the Higher Education Emergency Relief Fund (HEERF) created in the CARES Act

The House Energy and Commerce Committee bill includes more than $46 billion for COVID-19 national testing efforts and $20 billion to improve vaccine distribution. Additional funds will be used to incentivize states to expand their Medicaid programs, allow new mothers to stay on the program for up to a year, and eliminate a cap on Medicaid drug rebates beginning in 2023.

House Ways and Means Committee legislation has features that include capping the cost of coverage in the individual health insurance market through increasing Affordable Care Act (ACA) tax credits for 2021 and 2022. ACA plans would be available at no cost for individuals making up to 150% of the federal poverty level and also for unemployment insurance beneficiaries. The bill includes additional direct payments of $1,400 to individuals and an extension of temporary federal unemployment benefits.

Proposed legislation by the House Oversight and Reform Committee provides $340 billion to state and local government jurisdictions. Aid would be split with states receiving 60% of funding and localities obtaining the other 40%. This funding can be utilized for a host of different COVID related needs as determined by state and local officials, including further assistance to postsecondary institutions.

The House Small Business Committee would add $7.25 billion for the Paycheck Protection Program (PPP) and also create a new program to support the restaurant industry.

The Senate is expected to take up the House passed bill next week, with the House’s increase of the federal minimum wage to $15 in 2025 the item most at risk of being eliminated. In separate news, the important Senate Committee on Health, Education Labor & Pensions will have Patty Murray (D-WA) serve as chairperson and Richard Burr (R-NC) as ranking member.

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More May 2021 TRENDS Articles

MINISCULE CREATURES OF HUGE IMPORTANCE

A MAJOR FOCUS ON GOVERNMENT SPENDING

HEALTH REFORM DEVELOPMENTS

DEVELOPMENTS IN HIGHER EDUCATION

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

OBTAINABLE RESOURCES