FACETS OF HEALTH AND PERSONALIZED PROFILES FOR DISEASE RISK

Providing the best possible care for an individual means possessing a better understanding of the risks of developing disease. The goal is to have personalized answers when individuals need to know whether, for instance, preventive surgery makes sense, a given medicine is likely to be risky, or a certain diet should be recommended. According to an article in the September 9, 2021 issue of the journal Nature, information on genetic risk represents one promising approach to providing these answers. Genomic data, gathered across millions of individuals, have revealed thousands of DNA sequence variants associated with common diseases such as diabetes, heart disease, schizophrenia, and cancer. These clues to disease risk can be combined to generate ‘polygenic scores’ that provide a measure of the degree to which an individual genetically is predisposed to developing each such disease. A growing chorus of scientists and clinicians emphasize the value of such genetic profiling as an integral part of a personal medical record.

Alternatively, others argue that the clinical benefits have been massively overstated. This debate often fails to recognize that the challenge is not merely to improve understanding of genetic risk, but to capture more about the interwoven, multifaceted factors that play into disease risk. Perhaps a more pertinent argument would be that clinical medicine must learn to develop more-holistic measures of individual risk, both genetic and non-genetic, and to combine these with clinical data over time to deliver better care. Although current polygenic scores hold clinical promise, they come with several limitations. They leave out many sources of relevant data, and work best for the predominantly white, wealthy populations in which most genetic studies have been performed. The emphasis on genetic risk diverts attention away from non-genetic factors that might be equally important for disease risk and progression. Risk estimation on the basis of polygenic scores alone also fails to incorporate real-time measurements of clinical state that are especially important in diseases linked to aging. As a way of moving forward, researchers, funders, and industry need to embrace greater diversity in the design and implementation of studies, focusing not only on gender and ethnicity, but also on social, cultural, and economic factors that influence disease risk and access to health care.

OBTAINABLE RESOURCES

Population Health In Challenging Times

The year 2020 presented extraordinary challenges to organizations working to improve population health. As a means of understanding how various domains in the population health field are responding to and being changed by two major crises (racial injustice and the COVID-19 pandemic), the Roundtable on Population Health Improvement of the National Academies of Sciences, Engineering, and Medicine held a workshop on September 21-24, 2020, titled Population Health in Challenging Times: Insights from Key Domains. The workshop had sessions organized by themes, such as academic public health and population health; health care; and governmental public health. Each panel discussion highlighted difficulties and opportunities, both internal to the respective institutions and sectors, and at the interface with peers and partners, especially communities. A publication that summarizes the presentations and panel discussions from the workshop can be obtained here.

New Platforms Of Health Care

For the past century, health care measurement and delivery have been centered in hospitals and clinics. That arrangement is beginning to change as health measures and increasingly care delivery are migrating to homes and mobile devices. The COVID-19 pandemic has only accelerated this transition. While increasing access to care and improving convenience, this move toward platforms operated by for-profit firms raises concerns about privacy, equity, and duty that will have to be addressed. Also, this change in measuring health and delivering health care will create opportunities for educators to expand the settings for training, researchers to conduct studies at enormous scale, payors to embrace lower-cost clinical settings, and patients to make their voices heard. An article published on July 15, 2021 in npj Digital Medicine can be obtained here.

Geriatric Emergency Department Accreditation Program In The United States

Rapid growth in geriatric emergency departments (EDs) has been driven by Level 3 accreditation. Most geriatric EDs are in urban areas, indicating the potential need for expansion beyond those locations. Future research evaluating the impact of GEDA on health care utilization and patient-oriented outcomes is needed. The results of a recent study were published on August 10, 2021 in the journal Annals of Emergency Medicine. The objectives of this research were to describe the reach and adoption of Geriatric Emergency Department Accreditation (GEDA) program and care processes instituted at accredited geriatric emergency departments (EDs). Investigators analyzed a cross-section of a cohort of 225 EDs in the U.S. that received GEDA from May 2018 to March 2021. Only nine geriatric EDs were in rural regions. Significant heterogeneity existed in protocols enacted at geriatric EDs; minimizing urinary catheter use and fall prevention were the most common. The article can be obtained here.

Financial Impact of COVID-19 On Older Adults

A survey conducted by the Commonwealth Fund between March and June 2021 reveals that nearly one in five older Americans, particularly older Black and Latino/Hispanic Americans, indicate that they used up their savings or lost their main source of income because of the COVID-19 pandemic, a rate several times higher than in other high-income countries. The results of the study can be obtained here.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Top Global Causes Of Adolescent Mortality And Morbidity, 2019

According to an Infographic that was published in the October 2021 issue of the Journal of Adolescent Health, the causes of mortality among adolescents are different than the causes of morbidity. Injuries such as road injury, drowning, and self-harm; communicable diseases including diarrheal diseases, tuberculosis, and lower respiratory infections; and maternal conditions are the main causes of mortality among adolescents. Road injury is the leading cause of mortality among adolescent boys. Mental disorders including childhood behavioral, anxiety, and depressive disorders are among the leading causes of morbidity among adolescents of both sexes and across age groups. Iron-deficiency anemia is an important cause of morbidity among younger adolescents of both sexes. Another paper in that issue discusses how adverse health-related outcomes such as greater substance use, mental health difficulties, and higher BMI appear to be more likely to cluster together in the more recent cohort, with public health implications.

Adult Day Services Center Participant Characteristics: U.S., 2018

A Data Brief published on September 2, 2021 by the National Center for Health Statistics indicates that an estimated 251,100 participants were enrolled in adult day services centers (ADSCs) in the United States in 2018. Compared with users of other long-term care services, ADSC participants were younger and more racially and ethnically diverse. ADSC participants have a diverse set of needs, with many of them requiring assistance with activities of daily living (ADLs) and having chronic health conditions. About 57% of adult day services center (ADSC) participants were female, 45% were non-Hispanic white, and 39% were under age 65. Most ADSC participants were Medicaid beneficiaries (72%) while about 85% of participants under age 65 were Medicaid beneficiaries. About 64% of participants needed assistance with three or more activities of daily living. Most ADSC participants had two or three chronic conditions. Just over one-half of participants were diagnosed with high blood pressure.

HEALTH TECHNOLOGY CORNER

Persistence Of COVID-19 After Mild Infection

Uncertainty exists whether mild COVID-19 confers immunity to reinfection and questions also remain about the persistence of antibodies against SARS-CoV-2 after mild infection. A study published in the September/October 2021 issue of the journal Microbiology Spectrum reveals that approximately 90% of participants produced spike and nucleocapsid antibody responses, and all but one had persistent antibody levels at follow up. University of Michigan researchers analyzed nearly 129 subjects with PCR-confirmed COVID-19 illness between three and six months after initial infection. The prospective study’s participants either were Michigan Medicine health care workers or patients with a high risk of exposure to COVID-19. The results show that individuals who have mild COVID-19 illnesses and produce antibodies are protected from reinfection for up to six months afterward. Reinfection was not observed among individuals with mild clinical COVID-19, while infections continued in a group without known prior infection.

Shared Movement Disorders Walking Patterns Among Different Species

Neurodegenerative disorders including Parkinson’s disease, Alzheimer’s disease, and schizophrenia are conditions characterized by motor dysfunctions. Since the variables inherent to such diseases cannot be controlled directly in humans, behavioral dysfunctions and their neural underpinnings have been examined in model organisms. An article published on September 17, 2017 in Nature Communications describes how machine learning was used to obtain patterns from locomotion data created by worm, beetle, mouse, and human subjects that were independent of the species. Researchers at Osaka University trained a deep learning algorithm and used animal location tracking along with artificial intelligence to detect walking behaviors of movement disorders that are shared across species. By automatically removing species-specific features from walking data, the resulting information can be used to understand neurological disorders better, such as Parkinson’s disease that affect movement.

DEVELOPMENTS IN HIGHER EDUCATION

The U.S. Census Bureau announced on September 14, 2021 that median household income in 2020 decreased 2.9% between 2019 and 2020, and the official poverty rate increased 1.0 percentage point. Median household income was $67,521 in 2020, a decrease from the 2019 median of $69,560, making it the first statistically significant decline in median household income since 2011. Between 2019 and 2020, the real median earnings of all workers decreased by 1.2%, while the total number of individuals with earnings decreased by about 3.0 million and the number of full-time, year-round workers decreased by approximately 13.7 million. The official poverty rate in 2020 was 11.4%, up 1.0 percentage point from 2019, marking the first increase in poverty after five consecutive annual declines. In 2020, there were 37.2 million individuals in poverty, approximately 3.3 million more than in 2019.

This deteriorating income picture has enormous implications for students who wish to attend higher education institutions. During the 1950s and 1960s, for example, a great many students achieved a college education as commuters who lived at home and traveled to the campus each day by subway, bus, and carpool. Along with their books, they brought a lunch in a brown bag along with them. During the school year, they might have worked at supermarket checkout counters on the weekends and do the same or find other low paying employment in the summertime. The net result was that they could earn enough to cover tuition costs. Clearly, those days are gone forever and have been replaced by the accumulation of substantial amounts of student debt upon completion of community college and baccalaureate degrees. Unless conditions substantially are modified, the dream of attaining such degrees increasingly will be further out of reach for many individuals. This distressing prospect occurs at a time when the possession of a degree is associated more than ever with the likelihood of earning a decent salary.

Runaway Spending In Higher Education Institutions

A new report from the American Council of Trustees and Alumni points out that an onerous debt burden currently has reached an average of $39,351 for the 65% of students who borrow money to fund their college education. That face changes from grim to tragic for the 6% whose burden is greater than $100,000. Rationalizations for this economic catastrophe are viewed as ringing hollow. College debt does not comport with the dismissive description, “good debt,” once so popular among higher education administrators. High levels of student loan debt have been shown to postpone major life events dramatically, with borrowers reporting delays in saving for retirement (62%), buying a home (55%), marriage (21%), and starting a family (28%).

The Council does not envision debt forgiveness as a meaningful solution because it merely is a way of shifting the burden to the American taxpayer. More importantly, debt cancellation is but a temporary remedy that treats the symptom and not the disease. How, exactly, did the cost to attend college in the United States rise so high? A parallel consideration is that investment in instructional staff, particularly tenured or tenure-track professors, has been overshadowed by increases in administrative staff, namely well-paid, professional employees. A proposition is advanced that even the most optimistic would be hard-pressed to argue that colleges today are providing nearly three times the educational value that they did 30 years ago, which would otherwise justify the 178% increase in sticker price at four-year public institutions since 1990. This argument crumbles in the face of studies that show that one-third of students leave college without any growth in critical thinking or analytical reasoning skills and that only 49% of employers think recent graduates are proficient in oral and written communication.

The report illustrates the implications for students, both financially and academically, of the steady growth in spending since the Great Recession. It is hoped that public awareness of this trend’s impact on student finances and student outcomes will encourage more prudent choices. A proper understanding of an institution’s spending habits can provide valuable insights for governing boards seeking to allocate scarce resources efficiently toward what most benefits students.

HEALTH REFORM DEVELOPMENTS

The Patient Protection and Affordable Care Act became law in March 2010. Since then, it has been characterized by rulings issued from the offices of state attorneys general, appellate courts, and the U.S. Supreme Court, along with executive orders promulgated by the nation’s presidents and additional guidance provided by the Department of Health and Human Services in Washington, DC. It is conceivable that efforts to stay abreast of this ever growing cascade of information would tax even the energies of the most highly gifted Talmudic scholars were they ever to shift their attention in that non-heavenly direction.

Fortunately or not, there is a veritable army of interest groups represented in the nation’s capital to maintain a close watch on all imaginable health policy developments to ensure that every T is crossed and every I is dotted correctly. As an aside, it may not be hyperbolic to assert that every major piece of legislation in both the health and education realms just as easily could be subtitled the Attorneys, Accountants, and Lobbyists Relief Act of (fill in the appropriate year) since practitioners of those trades essentially are furnished with lifetime employment opportunities once enactment occurs.

One example of how muddles can bring matters to a halt can be traced to the mid-1970s. The services of physician assistants and advance nurse practitioners were unable to be reimbursed by Medicare unless a physician was present to observe and approve what they were doing. Unfortunately, rural areas of the U.S. are geographically vast in size and also characterized by physician workforce shortages. A bill was introduced in Congress to remedy the situation by indicating that a physician did not have to be physically present when services were being provided. All was proceeding swimmingly until a bill was produced with language that referred to these other personnel as physician extenders. Opposition was fierce because representatives of other professions viewed themselves as being independent qualified operators rather than mere extensions of physicians. It subsequently took more than an extra year to resolve that predicament in order to have the bill enacted. Welcome to the ways of Washington, DC.

Cost Effects Insurance Reforms Being Considered By Congress

Plans are being formulated on Capitol Hill to make permanent the American Rescue Plan Act’s temporary boost in subsidies for marketplace plans and to fill what is known as the Medicaid coverage gap. As part of the budget process for fiscal year 2022, which begins on October 1 this year, Congress is considering a package of two reforms to the Affordable Care Act (ACA). Under what is being developed, the enhanced premium subsidies included in the American Rescue Plan Act would become permanent. Also, the so-called Medicaid coverage gap would be filled by extending eligibility for marketplace subsidies to individuals earning below 100% of the federal poverty level in 12 states that have not yet expanded Medicaid.

Presently, there are about 5.8 million uninsured adults in those states that have incomes too high for that program, but not high enough to obtain marketplace subsidies. Together, these two health insurance reforms would sharply reduce the number of Americans under age 65 who lack coverage, according to a new analysis from the Urban Institute and the Commonwealth Fund. Not only would Black Americans see the biggest decline in the ranks of the uninsured, but uninsured numbers for white and Latinx/Hispanic adults also would fall significantly as well. Researchers project the changes would result in lower financial burdens for households struggling with health care costs.

Improving Health Care For The Nation’s Older Veterans

An announcement on September 9, 2021 from the Department of Veterans Affairs (VA) describes the launching of a nationwide movement to improve emergency department (ED) care for older veterans treated in VA Medical Centers and become the nation’s largest integrated health network with specialized geriatric emergency care. The VA Geriatric Emergency Department Initiative is a public-private collaboration between the VA, the American College of Emergency Physicians (ACEP), The John A. Hartford Foundation, and the West Health Institute to establish 70 of the VA’s EDs as accredited geriatric emergency departments (GEDs). These entities are better equipped to treat older adults with complex conditions while recent studies have found that GEDs can decrease hospital admissions and lower total healthcare costs.

BUDGET RECONCILIATION ON A MASSIVE SCALE

A key approach to achieve legislative objectives would be to use budget reconciliation procedures to pass some tax and spending measures in areas, such as Affordable Care Act enhancement and pandemic relief. The process begins with a budget resolution. Next, reconciliation legislation is then considered using a fast-track process that can be passed by a simple majority without having to be filibustered in the Senate. Limitations exist since 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.” Named after its principal sponsor, the late Senator Robert C. Byrd, D-WV), the rule provides six definitions of what constitutes extraneous matter. The Byrd rule has been in effect during Senate consideration of 22 reconciliation measures from late 1985 through the present.

During the month of September this year, various committees of jurisdiction in the House of Representatives have been working to advance major components of a $3.5 trillion reconciliation package. Examples include the following:

Education and Labor Committee

This group has been focusing on its portion of the Build Back Better plan, tuition assistance for community college students, increased funding for the Pell Grant program, and significant new investments in historically black colleges and universities, and other minority serving institutions.

Energy and Commerce Committee

Its members seek to address the “Medicaid coverage gap” and permanently extend the Children’s Health Insurance Program; allow the Medicare program to negotiate the prices of certain medications; invest in public health infrastructure and the health workforce; and fund pandemic preparedness efforts.

Ways and Means Committee

Constituents of this legislative body are considering medical education and other workforce issues; extending the expanded Affordable Care Act Marketplace premium tax credits from this year’s COVID-19 legislation; addressing drug pricing; and expanding Medicare benefits for dental, vision, and hearing.

Budget Committee

Participants involved in the activities of this entity ultimately will combine the health care measures with various education, housing, climate, and transportation provisions.

Apart from what occurs in the House, a Senate that lacks a majority by either of the two major political parties means that Democrats must be unified in their support. Although that party enjoys a majority in the House, the margin is slim. Thus, it will take only a small handful of Democrats to prevent the bill from being passed once it arrives on the House floor. If it does make its way to President Biden for his signature into law, it will be the most significant legislation of its kind since the New Deal in the 1930s.

BIOLOGICAL TECHNOLOGY PROSPECTS

Developments in the realms of science and technology continue to produce advances that not only are exciting, but also potentially frightening. Promising and controversial biological technology has included cloning, embryonic stem cells, and in vitro fertilization. More recently is the addition of CRISPR (clustered regularly interspaced short palindromic repeats), a tool for editing humans.

From the standpoint of achieving widespread public visibility, part of the story begins with the first publication of the idea of CRISPR in June 27, 2012 online in the journal Science by Jennifer Doudna of UC Berkeley and Emmanuelle Charpentier, a researcher born in France who was a faculty member at Umëa University in Sweden. They eventually were awarded the Nobel Prize in Chemistry in 2020. Shocking reactions occurred around the world in November 2018 when it was learned that two babies had been born in China with DNA edited while they were embryos, a development in genetics as dramatic as the 1996 cloning of Dolly the sheep. The two babies, nonidentical twin girls, were the first CRISPR’d individuals ever born as a result of experimentation by He Jiankui who claimed to have overseen the use of CRISPR to modify a gene in the human embryo called CCR5, a gene known to be important in allowing HIV to infect some human cells.

Readers with an interest in this topic may find it worthwhile to obtain a copy of a book that recently became available. It has the title, “CRISPR People: The Science and Ethics of Editing Humans” and it was written by Henry T. Greely, Professor of Law and Director of the Stanford Center for Law and the Biosciences at Stanford University. This author provides useful background information to the He Jiankui announcement and how CRISPR was used by that researcher.

Human germline genome editing and CRISPR are explained in this publication, along with a description of ethical discussions about and the legal status of such editing. Three chapters detail the revelation of Jiankui’s experiment and the fallout from those revelations. Part III of the text deals with assessments, while Part IV asks more broadly about human germline genome editing. For example, Professor Greely does not pull any punches by judging the experiment involving the two babies as criminally reckless, grossly premature, and deeply unethical.

One editing possibility involves enhancement, i.e., not for enhanced protection against diseases, but for producing better than normal traits or abilities for athletics, education, music, personal beauty, and other prized attributes. Focusing on that kind of intervention may not be the most beneficial way for CRISPR technology to proceed. Instead, somewhere between treating disease and enhancing traits would be to edit disease-prevention genetic variations into an individual’s genome. Rather than editing out an unusual pathogenic variation in favor of a common variant, the procedure could be used to edit out a common, normal-risk variant and turn it into an uncommon (or even) rare variation that lowers the risk below the population average. The author also notes that the real problems with introducing disease-prevention variations to a genome are not with the process, but with the result.

INCONSISTENT COMMUNICATION ABOUT COVID-19 VACCINES

According to a manuscript published in the July 2021 issue of the Journal of Communication in Healthcare, inconsistent communication about COVID-19 from public officials has created mistrust and confusion about public health recommendations, which has contributed to increased mortality in the United States. National, state, and local leaders have offered conflicting narratives about the seriousness of the pandemic, the steps needed to contain it, and the safety of the vaccines that are being administered. Much conflict has been over the choice of public health safety or the need to keep businesses and schools open. Framing this binary choice between public safety and the economy may be presenting a false dichotomy since containing the spread of COVID-19 is a prerequisite for a strong economy and a return to normal activities.

Language is viewed as playing an important role in the likelihood of motivating individuals to follow science-based public health recommendations and feel more confident about taking a COVID-19 vaccine. By a margin of 61% to 39%, one poll showed that respondents said the benefits of taking the vaccine would be more likely to motivate them than the consequences of not taking it. Moreover, gaining trust is particularly vital when communicating with members of vulnerable, marginalized, and underserved communities who regularly face systemic barriers and discrimination. Polling also examined differences in words that are likely to build trust about COVID-19 vaccines among Black and Latinx respondents. Overall, when these individuals were asked to choose the words that would give them the most trust and confidence in the COVID-19 vaccine (from a list of 12), the two most popular words were “advanced” and “groundbreaking.” Among Black respondents, however, the most preferred word was “innovative,” and for Latinx respondents, “unprecedented” was the first choice.

LANGUAGE CHOICE IN REDUCING STIGMA AROUND HEALTH CONDITIONS

Words used to describe mental illnesses and substance use disorders (addiction to alcohol and other legal and illegal drugs) can have an impact on the likelihood that individuals will seek help and the quality of the care they receive. Stigma, i.e., negative attitudes toward persons based on distinguishing characteristics may contribute in multiple ways to poorer health outcomes. An article published on July 19, 2021 in the journal Neuropsychopharmacology indicates that researchers and clinicians can help reduce stigma by carefully choosing the words they use to describe mental health conditions and addictions and the patients who are affected by them. Mental illnesses and substance use disorders always have been among the most stigmatized of health conditions. Because language can shape thoughts and beliefs, scientific communication sometimes may serve as an inadvertent vector of harmful stereotypes and assumptions.

A concern is that bias among medical professionals and mental health service providers can reduce the likelihood that individuals with mental illnesses will be offered or receive appropriate treatment or be referred for specialty care. Stigma against individuals with substance use disorders has proven particularly intractable. The public continues to see these disorders as character flaws or even as deviance, contributing to a treatment-averse mindset even among some physicians and health care providers. For example, some clinicians were more likely to favor punishment (a jail sentence) versus treatment for someone when that individual was described as a “substance abuser” versus having a “substance use disorder. Instead, using scientifically accurate language and terms that centralize the experience of patients who experience psychiatric conditions and that validate their worth can positively affect how they are treated within health care and in society more generally.

Similarly, the August 2021 issue of the journal The Gerontologist includes a paper discussing how in research Alzheimer’s Disease (AD) is referred to as a pathophysiological process, regardless of whether clinical symptoms are present, whereas in the lay literature, it is understood as a form of dementia. The two different uses of the term may result in misunderstandings, especially those research framings that falsely imply that patients with AD biomarkers inevitably will develop dementia. Adoption of the research understanding of AD in clinical practice will have normative implications, e.g., it legitimizes biomarker testing in individuals without dementia as improving “diagnostic” certainty.

OBTAINABLE RESOURCES

Federal Policy Priorities For The Direct Care Workforce

PHI has released a report entitled, "Federal Policy Priorities for the Direct Care Workforce." The document offers an extensive and detailed set of federal policy recommendations for that portion of the workforce. Throughout the United States, millions of direct care workers—home care workers, residential care aides, and nursing assistants—ensure that older adults and patients with disabilities have the support they need across care settings. The report proposes federal policy recommendations to strengthen the direct care workforce across eight issue areas: financing, compensation, training, workforce interventions, data collection, direct care worker leadership, equity, and the public narrative. The report also offers nearly 50 concrete recommendations for the White House, Congress, and key federal departments and agencies. It includes recommendations for navigating and learning from COVID-19. The report can be obtained here.

Reducing The Impact Of Dementia In The United States

The National Academies of Sciences, Engineering, and Medicine (NASEM) have released
a report detailing the path forward for the next 10 years of research on dementia in the behavioral and social sciences. The NASEM report recommends that research prioritize improving the lives of patients affected by dementia and of their caregivers; rectifying disparities; developing innovations that can improve quality of care and social supports; easing the economic costs of dementia; and pursuing advances in researchers’ ability to study the disease. The report also indicates that research will be most effective if it is coordinated to avoid redundant studies; ensures findings can be implemented in clinical and community settings; and takes policy and socio-economic implications into account throughout the course of a study. Funders of dementia-related research should incentivize these approaches and others in their guidelines for awarding research grants. The report can be obtained here.

The Future Of American Higher Education

The Director of the Georgetown University Center On Education And The Workforce offers his assessment of how the COVID crisis will result in long-term economic scarring of both individual students and postsecondary institutions in America. Viewed in the context of what might come next for postsecondary education, his sense is that COVID is just the beginning. As the pandemic subsides, it will open the way to demographic, economic, and policy changes that already were gaining momentum. He indicated that today’s postsecondary education and training system has become a new gearwheel, arguably the biggest gearwheel, in the American race and class inequality machine. The available evidence suggests that these two trends, the growing value of postsecondary education and its role in replicating race and class privilege, will continue and likely strengthen in the coming years. His views can be obtained here.

Can Health Organizations Improve Health Equity?

A report from the firm Deloitte addresses the question, “Can health care organizations move beyond lip service and take the steps needed to improve health equity?” The care patients receive and the outcomes they experience still can vary widely by race, age, income, ethnicity, gender, and even ZIP code. So, an issue worth exploring is whether health organizations can advance health equity. The report can be obtained here.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Provisional Life Expectancy Estimates For 2020

A report from the National Center for Health Statistics (NCHS) in July 2021 presents updated estimates of life expectancy based on provisional mortality data for the full year, January through December, 2020. Life expectancy at birth represents the average number of years a group of infants would live if they were to experience throughout life the age specific death rates prevailing during a specified period. In 2020, life expectancy at birth for the total U.S. population was 77.3 years, declining by 1.5 years from 78.8 in 2019. Life expectancy at birth for males was 74.5 years in 2020, representing a decline of 1.8 years from 76.3 years in 2019. For females, life expectancy declined to 80.2 years, decreasing 1.2 years from 81.4 years in 2019. The difference in life expectancy between the sexes was 5.7 years in 2020, increasing from 5.1 in 2019. Between 2000 and 2010, the difference in life expectancy between the sexes narrowed from 5.2 years to a low of 4.8 years and then gradually increased to 5.1 in 2019.

COVID-19’s Impact On Black Versus White Households

According to the results of a Pulse Household Survey released on July 21, 2021 by the U.S. Census Bureau, the coronavirus pandemic has produced higher rates of economic and mental health hardship for non- Hispanic Black adults (referred to as Black) than for non-Hispanic White adults (referred to as White) across several measures. Interpreting the results requires disentangling racial identity from other underlying conditions, such as poverty, lack of health insurance, and the greater likelihood in jobs where there is a higher risk of both infection and unemployment during the pandemic. The data suggest that the COVID-19 pandemic disproportionately affected Black households more adversely because the cumulative effects of job loss, food insufficiency, and financial insecurity resulted in uncertainty about how to pay for housing as well as more generalized anxiety. The fact that Black adults have been more likely than White adults to borrow money to make ends meet suggests that the pandemic’s impact may be prolonged as debts mount.

HEALTH TECHNOLOGY CORNER

Core Outcomes For Patients Living With Long COVID

A significant portion of patients diagnosed with COVID-19 subsequently experience lasting symptoms that include fatigue, breathlessness, and neurological complications months after the acute infection. Evidence for this condition is limited, however, and is based on small patient cohorts with short-term follow-up. An urgent need exists for the development of a core outcome set (COS) to optimize and standardize clinical data collection and reporting across studies and clinical practice. An international group of experts has developed a program of research with patient partners and the WHO called ISARIC (International Severe Acute Respiratory and emerging Infection Consortium) to develop a Post COVID-19 Condition COS. Post- COVID-19 Condition Core Outcomes will begin by surveying individuals living with the Post-COVID-19 condition, assess what outcomes matter, and build a plan in two phases. Phase One in 2021 will focus on what outcomes should be measured while Phase Two in 2022 will focus on how to measure these outcomes.

Longitudinal Association Of Total Tau Concentrations And Physical Activity With Cognitive Decline

Tau is a brain protein located in neurons and develops abnormally in individuals with Alzheimer disease. A study described on August 11 in JAMA Network Open describes an evaluation of the association of physical activity and total tau concentrations with cognitive decline at baseline and over time. Participants in the investigation are involved with the Chicago Health and Aging Project, a population-based cohort study conducted in four of that city’s communities. Study findings suggest that, among participants with both high and low total tau concentrations, physical activity was associated with slower cognitive decline. Results support the potential utility of blood biomarkers in measuring the benefits associated with health behaviors and may contribute to specifying target populations or informing interventions for trials that focus on improving physical activity behavior. A recommendation is that future work should examine the association of total tau concentrations with other health behaviors and physical activity types.

DEVELOPMENTS IN HIGHER EDUCATION

Approximately 23 million student-loan borrowers have benefited from a moratorium policy, which temporarily enables them to withhold making monthly payments on their federal debt load. Relating to the onset of the coronavirus pandemic, the pause on loan repayments and interest accrual went into effect on March 13, 2020 and was extended once to the end of that year. President Biden then extended it until September 30, 2021. In August, the moratorium was extended until January 31, 2022. It pertains to all loans held by the U.S. Department of Education, including Stafford, Grad PLUS, and consolidation loans. Some loans that originated under the Federal Family Education Loan (FFEL) are not eligible, however, since they are owned by private lenders.

Prior to these pauses, many students as a result of being unemployed or working in low paying jobs have found it impossible to pay their educational debts. Prominent Democrats have recommended using executive power to cancel as much as $50,000 of this debt for each borrower, while President Biden has indicated that it would be fair to do so in the amount of $10,000. Many congressional Republicans are less eager to provide such levels of relief. Depending on an individual’s status, debt has a differential impact on borrowers. One group of students who owe money consists partly of individuals who left school prior to completing degree programs. They are least likely to derive income from employment that enables them to pay back their loans. Another group is made up of students who might have debt as high as hundreds of thousands of dollars, but as graduates of post baccalaureate degree programs in medicine, law, and business, they are in a much stronger position to earn high paying salaries upon completing school.

Addressing The Educational Needs Of The Incarcerated

Individuals who enter penal institutions are not in an especially advantageous position to return to society upon being released from incarceration with a set of job skills in high demand by the employment sector. Instead, a further life of crime may be the only realistic way of producing income. Congress instituted a ban on the use of federal Pell Grants by incarcerated students in the Violent Crime Control and Law Enforcement Act of 1994 (P.L. 103-322). According to The Education Trust, the number of education programs in prisons subsequently dropped from more than 350 in 1990 to only a dozen in 2005. The percentage of incarcerated individuals participating in postsecondary education programs also dropped from 14% in 1991 to 7% in 2004.

The situation improved to some degree in December 2020 when Congress passed the Free Application for Federal Student Aid (FAFSA) Simplification Act, which reinstated prisoners’ access to Pell Grants. A next step is for the U.S. Department of Education to reverse Pell Grant restrictions. Otherwise, attainment of a college degree for prisoners remains challenging. The Education Trust indicates that correctional education programs reduce the rate of recidivism by 43%, increase the rate of employment after release by 13%, and are associated with fewer violent incidents in participating prisons. These programs are considered to result in net savings to taxpayers and are significantly more cost-efficient than incarceration alone. They also represent an essential strategy for breaking the cycles of incarceration and poverty, and helping formerly incarcerated individuals reintegrate into society.

New Negotiated Rulemaking Committee Meeting

The U.S. Department of Education on August 6, 2021 announced it will publish a notice in the Federal Register establishing a negotiated rulemaking committee that will meet virtually beginning in October of this year to rewrite regulations for Public Service Loan forgiveness, income-contingent repayment plans, and borrower defense to repayment, among other issues. These regulations will help borrowers manage repayment or receive a discharge or forgiveness of their federal student loans. The committee also will establish regulations to implement Pell Grant eligibility for incarcerated individuals, which will be discussed in a subcommittee. In the notice, the Department requests nominations for negotiators and sub- committee members and sets dates for negotiation sessions.

HEALTH REFORM DEVELOPMENTS

According to a new report from The Commonwealth Fund entitled, Mirror, Mirror 2021: Reflecting Poorly, the U.S. health system trails far behind its counterparts in 10 high-income peer countries when it comes to affordability, administrative efficiency, equity, and health care outcomes. Unique in measuring and comparing patient and clinician experiences across nations, the report shows that in the U.S., an individual’s chance of obtaining good health care depends to a large extent on income, more so than in any other wealthy country. The U.S., which spends the most per individual on health care, has ranked last in every edition of the report since 2004. Also, this nation has fallen even further behind on certain measures, especially health outcomes linked to primary care access and equity in care delivery.

Readers of this issue of ASAHP’s newsletter who have grown long in the tooth over the decades may recall a popular tune performed by Creedence Clearwater Revival in 1969 called Bad Moon Rising. Some of its lyrics are:

I see the bad moon a-rising
I see trouble on the way
I see earthquakes and lightnin'
I see bad times today

Oddly enough, despite the negative appraisal of health care in the U.S., this nation is distinguished by having world class centers that attract patients from all over the globe who seek the best in what these facilities have to offer. A major problem is that not all U.S. inhabitants are in a position to have equal access to such high quality care due to a factor, such as lack of adequate health insurance. Another relevant circumstance is what has been labeled “deaths of despair.” Angus Deaton and Anne Case at Princeton University have been successful highlighting a rise in mortality rates caused by inappropriate drug use, suicide, and alcoholic liver disease. They have noted that expected years lived between ages 25 and 75 declined for most of a decade for men and women without a four-year degree, even prior to the arrival of COVID-19. An article they wrote in the March 16, 2021 issue of the Proceedings of the National Academy of the Sciences in the USA discusses the link between possessing a college degree and the opportunity to obtain jobs that provide sufficient income. Ensuring the attainment of suitable levels of education, adequate employment prospects, decent housing, impact of discrimination, lack of necessary health resources in rural areas, and low crime neighborhoods are some multifactorial examples of the complex nature underlying efforts to improve individual and community health status.

State Initiatives To Improve Health Care

Because of its involvement in research funded by the National Institutes of Health, the financing of health services through Medicare, and the direct provision of such services through various government entities that include the Veterans Administration, the federal government rightly attracts significant attention when discussing health policy issues. Nonetheless, states around the nation also play key fundamental roles in attempts to foster a healthy population. Since taking office, the Biden administration has tried to enhance the Affordable Care Act (ACA) by reversing policies implemented when Donald Trump was President, such as the latter’s decision to eliminate a policy encouraging standardized health plan designs for marketplace coverage. Researchers at the Georgetown University Health Policy Institute believe that the federal government can learn from examining how states are using plan standardization to improve access to care. For example, cost barriers could be lowered by exempting critical primary care or mental health services from deductibles.

In a separate related arena, the Pew Charitable Trusts in its Legislative Review 2021, points out that local and state public health officials wield extraordinary powers in emergency situations, such as the present coronavirus outbreak. They can close schools and private businesses. They can restrict or shut down mass transit systems. They can cancel concerts, sporting events and political rallies. They can call up the National Guard when necessary. They can suspend medical licensing laws and protect physicians from liability claims. Not only can they quarantine or isolate some individuals who might infect others, they have the authority to implement policies that involve social distancing and the wearing of masks.

THE CHALLENGING ROAD TO ENACTING LAWS

Each year, thousands of bills are introduced in Congress. The 1st Session of the 117th Congress in 2021 is no exception. As of August 13 this year, 5,039 bills were introduced in the House and 2,712 in the Senate as of August 11. Any measure perceived as being of great national importance may undergo certain stages. Once it is referred to a particular committee, members of that group may invite both government and non-government experts to testify at a public hearing about the necessity of having such legislation be enacted into law. A related step is to have the Congressional Budget Office (CBO) produce a score regarding a proposal’s potential budgetary impact.

Although this information may come from numerous sources, according to the Congressional Research Service (CRS), Congress generally relies on estimates provided by CBO and the Joint Committee on Taxation (JCT) when determining whether proposed legislation complies with congressional budgetary rules. Generally, CBO and JCT estimates include projections of the budgetary effects that would result from proposed policy changes, and incorporate anticipated individual behavioral responses to the policy. The estimates, however, do not typically include the macroeconomic effects of those individual behavioral responses that would alter gross domestic product (GDP). In recent decades, Congress sometimes has required that JCT and CBO provide estimates that incorporate such macroeconomic effects on overall economic output. i.e., GDP. These estimates often are referred to as dynamic estimates or dynamic scores.

A good example of proposed legislation that recently underwent this level of scrutiny is H.R. 3684, The INVEST in America Act. It was introduced in the House on June 4, 2021 and was passed by the Senate on a 69-30 Yea-Nay Vote on August 10. This bill addresses provisions related to federal-aid highway, transit, highway safety, motor carrier, research, hazardous materials, and rail programs of the Department of Transportation (DOT). CBO found that the roughly $1 trillion infrastructure bill would widen the budget deficit by $256 billion over 10 years, which is in contrast to bill negotiators’ claims that the cost of the legislation would be covered by new revenue and savings measures. Legislators who supported passage indicated that the CBO assessment does not reflect savings and additional revenue identified in other estimates, noting that the agency is limited in what it can include in its formal score.

Whether H.R. 3684 will be enacted into law depends on whether a second piece of major legislation favored by Democrats that is considered as complementary to H.R. 3684, and estimated by its supporters as costing $3.5 trillion, also is approved by Congress. Senate Democrats approved a budget resolution (Senate Concurrent Resolution 14) for that amount on August 11. These large sums of money call to mind two sagacious aphorisms. One of them was made by Niels Bohr, a Danish scientist who won a Nobel Prize in Physics in 1922. He stated, “Prediction is very difficult, especially if it's about the future,” a comment that is quite apropos in the context of estimating projected legislative revenues and costs over the next 10 years. Former Senate Minority Leader (from 1959-1969) Everett Dirksen (R-IL) once quipped at a time when a billion dollars seemed like an enormous amount of money, “A billion here, a billion there, and pretty soon you're talking about real money."

IMPORTANCE OF ACCURATE FRAMING

Depending on how any issue is framed, it can have an impact on how: a problem will be defined, its etiology will be delineated, and remedies will be formulated. In an article published in the January 30, 1981 issue of the journal Science, a pair of Israeli psychologists, Daniel Kahneman and Amos Tversky, shed early light on the relevance of this topic by discussing how health messages can be framed in either the benefits of engaging in a recommended behavior (gain-framed messages) or the costs of not engaging in that behavior (loss-framed messages). Although conveying essentially identical information, one form of message-framing may be more effective at promoting health behavior change than the other.

For example, they conducted a study in which they asked respondents to imagine that the U.S. is preparing for the outbreak of an unusual Asian disease, which is expected to kill 600 victims. Two alternative programs to combat the disease were proposed. These researchers found that choices involving gains are often risk averse and choices involving losses are often risk taking. The only effective difference between the two programs is that outcomes were described in one problem by the number of lives saved and in the other by the number of lives lost. Kahneman’s doctorate is from Berkeley and while serving at Princeton, he was awarded the Nobel Prize in Economics in 2002 for his body of work. Tversky died in 1996. Nobel awards are not made posthumously.

Unlike their study, today the world actually continues to experience the ill effects of a coronavirus pandemic. As a means of preventing a future outbreak of a highly deadly communicable disease, it is important to learn how COVID-19 originated. One school of thought proposes that the cause was natural, resulting from the consumption of food by humans in the form of bat and pangolin meat sold in wet markets in China. An entirely different frame asks whether the disease emerged as a result of a leak in a Wuhan virology laboratory where gain-of-function research was conducted to convert a virus into a more deadly and transmissible form. Each frame differs considerably from the perspective of the kinds of effective safeguards to construct to prevent the appearance of a similar pandemic anytime in the future.

Another major concern of policymakers in the U.S. is an opioid epidemic that continues to produce fatal consequences for users of addictive substances. One approach is to frame the problem as a health issue. Corrective measures might focus on: prevention, development of improved treatment protocols, increased financial support for recovery facilities, and discovery of less addictive substances and more effective non-medication kinds of interventions to reduce levels of pain. An entirely different approach would be to frame the opioid problem as essentially being of a law enforcement nature. Proposed remedies could include tighter restrictions at the nation’s southern border to prohibit the criminal activity of drug cartels and the infliction of harsher penalties when drug dealers are apprehended. Perhaps implementing a combination of the two approaches might work best, but when resources are limited, it may be necessary to select one choice to the possible detriment of the other alternative.

OBTAINABLE RESOURCES

Innovative Funding Models During COVID-19

A report from AcademyHealth supplements an earlier Paradigm Project Horizon Scan published in 2019 that examined innovative alternatives to peer review as the basis for allocating research funds. Since then, the COVID-19 crisis has brought into sharp focus the importance of research and scientific advancement in modern society. Facing a global pandemic, there is an urgent need to find solutions through research, not just to vaccines and treatments to address COVID-19 directly, but also wider investigations to address broader challenges faced by society. The 2019 report is updated to add a review of a range of different approaches used to support research related to COVID-19: public engagement and crowdfunding; flexibility in use of funding and resources; adapting application and decision processes to ‘fast-track’ funding; coordination and access; and prizes. The scale and speed of the changes in approach and openness to new funding routes is unprecedented and presents an opportunity for change and learning. It also is worth noting that at present there is little evidence on the effectiveness of these different approaches. Over the longer term, it will be important to evaluate how well these novel mechanisms performed in directing funding quickly and appropriately to learn what works. The report can be obtained here.

Senior Report: America’s Health Rankings

A nearly 60% increase in the population of older adults in the next 30 years is projected, according to the United Health Foundation's latest Senior Report, which measures the state of the physical, mental, and social health of older adults in the U.S. The analysis, which largely included data from 2019, finds that there will be nearly 86 million individuals aged 65 and older by the year 2050, up from 54 million in 2019. Even before the pandemic upended their health, this population was experiencing worsening health outcomes, including a nearly 40% increase in drug-related deaths since 2014 and an 11% increase in frequent mental distress from 2016-2019. At the same time, care for this group also improved in some areas in recent years, including increases in geriatric providers, flu vaccination rates, and exercise rates. The report can be obtained here.

Grant Review Feedback: Appropriateness And Usefulness

An article published earlier this year in the journal Science and Engineering Ethics indicates that the primary goal of the peer review of research grant proposals is to evaluate their quality for the funding agency. An important secondary goal is to provide constructive feedback to applicants for their resubmissions. Little is known, however, about whether review feedback achieves this goal. For example, although not listed as a core value of the NIH peer review system, reviewer feedback to applicants for the purposes of improving investigator grantsmanship and the overall quality of applications is an important, if secondary, purpose of grant peer review. The paper presents a multi-methods analysis of responses from grant applicants regarding their perceptions of the effectiveness and appropriateness of peer review feedback they received from grant submissions. Overall, 56–60% of applicants determined the feedback to be appropriate (fair, well-written, and well-informed), although their judgments were more favorable if their recent application was funded. Importantly, independent of funding success, women found the feedback better written than men, and more white applicants found the feedback to be fair than non-white applicants. Also, perceptions of a variety of biases were specifically reported in respondents’ feedback. Fewer than 40% of applicants found the feedback to be very useful in informing their research and improving grantsmanship and future submissions. Further, negative perceptions of the appropriateness of review feedback were positively correlated with more negative perceptions of feedback usefulness. Importantly, respondents suggested that highly competitive funding pay-lines and poor inter-panel reliability limited the usefulness of review feedback. Overall, these results suggest that more effort is needed to ensure that appropriate and useful feedback is provided to all applicants, bolstering the equity of the review process and likely improving the quality of resubmitted proposals. The paper can be obtained here.

ANIMAL PREDATORS AND ACHIEVEMENT OF HUMAN SOCIAL GOOD

Wolves represent a type of predator threatening livestock, such as cattle and sheep. Able to cover vast distances traveling in packs, the species canis lupus, the gray wolf, can develop an enormous appetite on long journeys in search of food. Any creatures unfortunate enough to be in their path soon become a tasty comestible on such occasions. Wolves generally are not associated with pleasant imagery, a view revealed in the tale of Little Red Riding Hood or by the expression “a wolf in sheep’s clothing,” which reflects an unsavory human character. A more recent appraisal, however, suggests that wolves may have the capacity to add to human betterment.

Humans nearly eradicated the species from the continental U.S. by the 1960s, but legal protections strengthened during the latter half of the 20th century made it possible for about 5,500 wolves to exist in 10 coterminous states today. According to an article published on June 1, 2021 in the journal Proceedings of the National Academy of Sciences of the USA, researchers quantified the effects of restoring wolf populations by evaluating their influence on deer–vehicle collisions (DVCs) in Wisconsin. They show that, for the average county, wolf entry reduced DVCs by 24%, yielding an economic benefit that is 63 times greater than the costs of verified wolf predation on livestock. Most of the reduction is due to a behavioral response of deer to wolves rather than through a deer population decline from wolf predation. Findings suggest that wolves control economic damages from overabundant deer populations in ways that human deer hunters cannot. Deer numbers have surged, increasing from about 2-4 deer per km2 in the precolonial era to 15-50 deer per km2 in some areas, affecting ecosystems by suppressing forest regeneration; altering the composition of tree and herbaceous plant species: contributing to the spread of invasive species; and causing Lyme disease through deer tick infestation.

TECHNOLOGY, HEALTH MONITORING, AND PRECISION HEALTH

Technological advances exert a vast impact on health care and the future promises to bring forth new developments that will affect health monitoring and precision health. As described in the June 2021 issue of the journal Science Translational Medicine, genomic analysis has allowed for even more precise risk assessment, and the current pace of technological advancement could make it feasible to genotype infants at or before birth. The genome is far from the only contributor to disease and must be considered in conjunction with its complement the “exposome,” which comprises the totality of environmental exposures over the course of one’s lifetime, including internal exposures, such as the body’s microbiome and oxidative stresses. Personalized disease risk can be determined from genetic and exposure risk factors and used to create an individualized model of health. Meanwhile, a broader understanding of health status is being pursued in efforts such as Project Baseline (www.projectbaseline.com/) and the Precision Medicine Initiative “All of Us” cohort (https://allofus.nih.gov/), which are collecting data from tens of thousands of participants to build a model of human health and disease. This model provides an individualized baseline for personalized health, and the collective data can be used to build a framework for population-based health predictions.

Wearable health monitoring devices have become increasingly prevalent among consumers. The development of flexible electronics has further expanded the field of wearable technologies into textiles and beyond. Additionally, tear biomarker discovery is at an early stage of development for conditions other than ocular disease. Saliva also is being investigated as a diagnostic fluid and is a noninvasive source of many of the same biomarkers that are present in serum, even biomarkers for nonoral cancers for example. Also, sweat analysis recently has been reported in a headband and wristband containing flexible sensors that are capable of processing and transmitting data regarding hydration and electrolyte concentrations. All these innovations have significant potential to improve the health status of individuals, but key challenges exist. There will be no shortage of health data from continuous health monitoring sensors and efforts such as Project Baseline and All of Us, but proper interpretation of these datasets will be challenging. The unprecedented influx of continuous health monitoring data for parameters that are not normally measured at such frequencies will require an entirely new process for validation and guidelines on interpretation. Another hurdle will be management of the sheer amount of data generated. Further hurdles in the path of precision health include issues of privacy and regulatory oversight, as well as the behavioral psychology of keeping users engaged in various practices.

HEALTH REFORM DEVELOPMENTS

In his book, Reflections On The Revolution In France, Edmund Burke stated in 1790: “When I see the spirit of liberty in action, I see a strong principle at work; and this, for a while, is all I can possibly know of it. The wild gas, the fixed air is plainly broke loose: but we ought to suspend our judgment until the first effervescence is a little subsided, till the liquor is cleared, and until we see something deeper than the agitation of a troubled and frothy surface.” Some ambitious plans by President Biden and congressional Democrats are at a juncture where various restraints in policy-making progress are beginning to manifest themselves as both intra- and inter-party disagreements become more prominent, revealing that some early froth has begun to subside.

June 17, 2021 marked another important day in the history of the Affordable Care Act. The U.S. Supreme Court on a 7-2 vote ruled that a lawsuit led by several Republican states and the former Trump administration challenging the constitutionality of this legislation did not have legal standing because the provision did not injure the plaintiffs. The decision preserves the law, thus guaranteeing continued access to health plans by its beneficiaries. The case centered upon the constitutionality of maintaining the ACA in place after the penalty for the individual mandate, a requirement that individuals enroll in a health insurance plan, had been zeroed out. In a decision in 2012, the court ruled on a 5-4 vote that the penalty was a tax. When a 2017 reform law eliminated the tax, plaintiffs argued that the entire law no longer was constitutional.

Medicare’s Role In Meeting The Costs Of Vaccinations For COVID-19

As a major force in the provision and financing of health care services, the Medicare program is making it possible to furnish assistance for home-bound beneficiaries who have difficulty meeting the costs of being vaccinated during the current pandemic. The agency has agreed to pay an additional $35 per dose for COVID-19 vaccine administration in that setting. The purpose is to facilitate access to immunization for individuals who find it difficult either to leave their homes or seek vaccinations in a community setting. The Centers for Medicaid & Medicaid Services (CMS) estimates that the policy will aid 1.6 million adults age 65 and older. An additional payment increases the cost per vaccine dose from $40 to $75, depending on geographic location to account for costs associated with providing the vaccine at home and monitoring patients after the drug is administered.

In a related action, U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra notified insurers and providers in a letter sent on June 9, 2021 to remind them that they have signed agreements to cover the administration of COVID-19 vaccines free-of-charge to patients, and group health plans and health insurers of their legal requirement to provide coverage of COVID-19 vaccinations and diagnostic testing without patients encountering any cost.

Limits Imposed On Use Of The Reconciliation Mechanism For Budgetary Matters

The December 2020-January 2021 issue of the newsletter in this column explained how Congress is able to use budget reconciliation procedures to pass some tax and spending measures in areas, such as Affordable Care Act enhancement, pandemic relief, and climate change. The process begins with a budget resolution. Next, reconciliation legislation is then considered using a fast-track process that can be passed by a simple majority without having to be filibustered in the Senate. This approach has attractive features since the Senate is split 50-50. Democrats expressed considerable enthusiasm over the prospect of using multiple reconciliation initiatives to advance President Biden’s Build Back Better, which is a comprehensive undertaking aimed at enacting the American Jobs Plan, the American Families Plan, and various health care reform proposals designed to expand the Medicare program and lower the price of prescription drugs.

Their hopes were dashed, however, when Senate Parliamentarian Elizabeth MacDonough ruled that Democrats can only use the budget reconciliation process one more time during 2021 to pass one legislative package with a simple-majority vote. Her position is that a revision to the 2021 budget resolution cannot be discharged automatically from the Senate Budget Committee, requiring Democrats to secure at least one Republican vote on a panel where members are split 11-11 along party lines.

PROJECTED GOVERNMENT SPENDING

Coming weeks and months will help to define how much money the federal government will allocate for a wide variety of purposes that affect health care and higher education both in calendar year 2021 and in the upcoming new fiscal year that begins next October 1. Spending occurs in three major ways.

Mandatory spending represents the largest share of the government’s budget. Amounts are not fixed and some money is directed to what are called entitlement programs, such as Medicare and Social Security. The key determinant is eligibility to participate in these programs. Once individuals are deemed eligible, the government is obliged to pay whatever costs are involved in meeting its obligations.

Expenditures that tend to merit the most attention in the mass media are called discretionary. They can vary in amounts from one year to the next and depend on agreements being reached on how much of a President’s proposed budget will be accepted by Congress. Oftentimes, amounts for the 12 major categories are not agreed upon for the start of a new fiscal year. Whenever that situation occurs, either short-term or long-term continuing resolutions known as CR’s enable the government to continue functioning uninterrupted. Sometimes, the final outcome is the enactment of omnibus legislation that encompasses several of the 12 appropriation bills.

A third important type of spending affects the academic community and it involves student financial support. One aspect pertains to student loans, a topic that regularly is addressed in this newsletter. Congress sets the terms regarding how much money will be dispersed to colleges and universities to benefit student borrowers. Current overall student debt is approximately $1.7 trillion. Many individuals find it extremely difficult to repay their loans. Policymakers often debate whether it is feasible to forgive a portion of this debt.

As reported on this page in the April 2021 issue of this newsletter, the Biden administration submitted a preliminary budget proposal to Congress on the 9th of that month for FY 2022. A more complete version was sent on May 22. Some of its main spending requests include:

• $131.8 billion for Department of Health & Human Services (23.5% increase over FY 2021)

• $51.9 billion for National Institutes of Health (21% increase over FY 2021)

• $9.5 billion for Centers for Disease Control & Prevention (21.4% over FY 2021)

• $7.8 billion for Health Resources & Services Administration (8.5% over FY 2021)

• $854 million for HRSA’s Title VII Health Professions and Title VIII Nursing (12.1 % over FY 2021)