HEALTH REFORM DEVELOPMENTS

Another section of this December 2021-January 2022 issue of the ASAHP newsletter TRENDS has a list of three obtainable resources electronically that pertain to: health care disparities; uneven allocation of health insurance deductibles and premiums among consumers in different states in the U.S.; and how usage of telehealth services by Medicare beneficiaries varies around the nation based on ethnicity and urban-rural residence patterns. Policymakers at the national level often discuss where the locus of control might best be centered in dealing with such matters. The federal government has enormous resources at its disposal to respond to a wide range of health problems. As an illustration, although 21 major federal agencies in more than 100 offices are spread around the U.S. to combat the COVID pandemic, it remains highly challenging to develop an effective administrative structure to coordinate all these entities to prepare for and respond to this disease. Another potential downside is that any effort resembling a one-size national approach may lack the necessary heft to meet the kinds of various situations that exist around the nation.

Perhaps even more importantly, centralization of authority rests on a major assumption that effective action can be taken in the face of an enormous amount of administrative diversity that exists within states, counties, cities, and towns. Whenever a health problem arises, health departments at each of these levels have different capabilities in the form of possessing suitable amounts of key staff and the resources necessary to produce desirable outcomes. These governmental units also differ significantly from one another based on the kinds of consumers being served. Demographic factors, such as age, race/ethnicity, degree of health insurance coverage, and urban-rural residential patterns all play a determinative role in how successfully local health problems can be addressed. One-size remedies promoted nationally often tend to lack more customized interventions needed to deal with the wide variability that characterizes local jurisdictions.

Expansion Of Health Insurance Coverage
On the plus side of noteworthy developments, the Biden Administration’s American Rescue Plan has made it possible for millions of more consumers' to become eligible for health care coverage that began January 1, 2022 through the Affordable Care Act (ACA) Health Insurance Marketplaces. The effort started on November 1, 2021 and had a closing date of January 15 this year while managing to outpace previous years’ enrollment. Total nationwide plan selections include more than 14 million consumers (15% of the total) who are new to the Marketplaces for 2022 and returning consumers (85% of the total) who have active 2021 coverage and made a plan selection for 2022 coverage or were re-enrolled automatically.

Rural Health Care Developments
The Agency for Healthcare Research and Quality (AHRQ) released an updated Chartbook on Rural Healthcare that discusses how rural area inhabitants face difficulty obtaining timely, high-quality, affordable services. Approximately 60 million Americans live in rural communities that often are a considerable distance from needed resources, which can add to the burden of obtaining care. Census Bureau data show that about 20% of the population lives in rural or nonmetropolitan areas, although about 85% of the total U.S. land area is classified as rural. Ten million rural residents identify as Black, Hispanic, American Indian/Alaska Native, Asian American/Pacific Islander, or mixed race. One in five rural residents belongs to one or more of these groups. Regrettably, availability and collection of robust data on health outcomes of these population groups remain limited. Also, compared with urban counties, their rural counterparts differ in fundamental ways, such as having a higher prevalence of adults with multiple chronic health conditions (e.g., arthritis, diabetes) (34.8% vs. 26.1%).

COVID-19 Effect On Health Care Expenditures
The COVID-19 pandemic has had a dramatic impact on the nation’s health sector in 2020, driving a 9.7% growth in total national health care spending as it rose to $4.1 trillion. This figure is one of many health care expenditures presented in the 2020 National Health Expenditures (NHE) Report, prepared by the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS). Medicare spending totaled $829.5 billion in 2020, representing 20% of total health care spending. Medicaid spending grew faster in 2020, increasing 9.2% to $671.2 billion compared to 3.0% growth in 2019, primarily driven by increased enrollment due to the pandemic.

SEASONAL UNCERTAINTIES

The 2nd Session of the 117th Congress was launched in January 2022, but a picture of what will unfold in coming months continues to be somewhat opaque. For example, the likelihood of passing a multi-trillion dollar “Build Back Better” tax and spending reconciliation package (H.R. 5376) previously has been discussed in this newsletter. An important piece of legislation, its aims involve expanding Medicare to include hearing, two free years of community college, universal pre-kindergarten, and creation of a program encouraging utilities to reduce carbon emissions. Opponents contend that not only are some components of the bill wasteful, but also have the potential through proposed tax increases to inflict substantial harm on the overall economy. As with other large proposed spending measures, debates focus on how to finance the various provisions, especially if increased taxation is required.

The ongoing presence of the coronavirus pandemic keeps alive concerns that perhaps additional federal efforts are needed to ensure that enough is being accomplished in the related areas of vaccine distribution and development of effective therapeutics. Specifically, Congress may need to decide that more funding is necessary to address these aspects of health protection for the U.S. population. One possibility might be to produce an emergency supplemental spending package aimed at furnishing more resources to increase hospital and testing capacity.

More generally, February 18 has been designated as a deadline to continue federal government funding for the rest of the current fiscal year that draws to a close on September 30. As in previous years, it is proving difficult to agree on what the total amount of spending should be. Legislators do not appear to be close to reaching an agreement on either total spending or whether to rely on either another stopgap spending bill or an omnibus package.

Unlike 2021, the 2nd Session of the 117th Congress will not last as long as the 1st Session because of the upcoming midterm elections. Viewed from the perspective of bills that involve the topic of health, in 2021 there were 795 bills introduced in the House and 464 in the Senate. Often, many bills are companion pieces and have the same contents offered for consideration by legislators in each chamber. Despite these relatively large numbers, each year a much smaller group ever makes it to the enactment stage. In 2021, the following measures attained that status: P.L. 117-71, Protecting Medicare and American Farmers from Sequester Cuts Act; P.L. 117-11, FASTER Act of 2021; P.L. 117-9, A Bill to Amend the Federal Food, Drug, and Cosmetic Act with Respect to the Scope of New Chemical Exclusivity; and P.L. 117-8, Advancing Education on Biosimilars Act of 2021.

As the year progresses, it is likely that more individuals will announce that they will not seek reelection in the midterm races that will be decided next November. Some legislators plan to run for a different kind of office, but most are retiring for other reasons. If Republicans eventually assume control in both chambers, the change could have a negative impact on the ability of President Biden to achieve his policy agenda.

TECHNOLOGICAL IMPACTS ON HEALTH

The arrival of the coronavirus in the U.S. nearly two years ago immediately began producing enormous changes in the workplace. As a result of lockdowns and social distancing policies around the nation, chief among these alterations was that millions of workers lost their jobs. Fortunately for certain kinds of employees, many of them were able to remain at home performing essential tasks. In the health professions, tools such as Zoom and telehealth made it possible for many educators, students, and clinicians to function successfully without having to be in an office, classroom, or clinic.

Less well heralded, but still of increasing relevance apart from the pandemic, are many technological developments with the potential to transform not only the workplace, but also to have an impact on enhancing individual and community health status. For example, newer direct-reading sensor devices are incorporating recent advances in electrochemical, optical or mechanical transducers; nanomaterials; electronics miniaturization; portability; batteries with high-power density; wireless communication; energy-efficient microprocessing; and display technology. Commercial applications of new sensor technologies have led to a variety of health and lifestyle management devices for everyday life. These digital health technology tools, such as fitness trackers, smartwatches, and smartphones function as real-time monitors of various physiological and disease-related signals. Technologies of this nature have led to advances in connected health, telemedicine, sports analytics, ambient intelligence, and workplace “physiolytics.”

According to an article published in the January 2022 issue of the American Journal of Industrial Medicine, existing and newer sensor technologies can be categorized into broad categories. Placeable sensor devices can be placed in and around the workplace to collect information from the ambient work environment. The vast majority of extant Wearable sensors can be attached to a worker's clothing, head, arms or wrists, upper/lower body, or feet, worn as computer-display eyeglasses, or contact lenses, or placed in the ear canal. Moreover, current research into the role of wearable sensing technologies in the construction industry has focused on how sensors can aid in detecting and monitoring risk factors that lead to work-related musculoskeletal disorders (WMSDs), falls from elevated heights, and physical fatigue. Implantable sensors constitute a third variety of new items that can be inserted into the skin via microneedles, microchips, or by ingestion.

As these new implements become more commonplace, key questions arise. One is which population subgroups will tend to benefit most from the widespread adoption of such technological instruments? Closely related to the issue of which individuals will be able to obtain products that can enhance their personal health status is the important matter of how to pay for them. Substantial portions of the U.S. population are at a major disadvantage that results from health care inequities. The major health care financing programs Medicare and Medicaid are not in an enviable position to absorb new significant expenditures to ensure that health technology innovations are spread equitably across the population.

RESIDENTIAL DISORDER AND BIOLOGICAL MARKERS OF AGING

Residential context is important to older adults’ health. Numerous studies have linked adverse residential conditions, such as physical disorder, to poorer functional status, chronic health conditions, and cognitive decline. A growing literature investigating possible physiologic pathways between residential contexts and health has focused on biological markers. As indicators of normal biological processes, biomarkers may reflect aging-related health and functional changes and have been linked to morbidity and mortality. For example, inflammatory markers, such as C-reactive protein (CRP) and interleukin-6 (IL-6), are associated with physical function decline, cardiovascular disease, and mortality in older adults, but the underlying biologic mechanisms remain understudied. Thus, examining the relationships between adverse street block conditions and biomarkers of aging would further an understanding of the physiological mechanisms through which residential context influences aging and health. A study described in the November 2021 issue of the Journals of Gerontology Series A: Biological Sciences and Medical Sciences was to test associations between adverse street block conditions and biomarkers of aging among a nationally representative cohort of US adults aged 67 years and older.

The investigators posit that smaller area units should be considered because older adults’ life space can decrease with the onset of age-related health or functional limitations. Conditions of the residential environment proximate to the home, such as the street block on which the home is situated, may be more influential in older adults’ everyday lives than the wider neighborhood context. They hypothesized that the presence of any street block disorder is associated with higher levels of four biomarkers of aging: hemoglobin A1C, high-sensitivity CRP, IL-6, and CMV antibodies. They found that participants living on disordered blocks were more likely to be Black or Hispanic than White, have a high school education or less, and have a lower average income to poverty ratio compared to participants living on blocks with no disorder. These participants also were more likely to experience financial strain, be unmarried, rent their home, have a larger mean household size, live in a non-single-family type home, have had less than average family wealth growing up, and have been born outside the United States.

TRENDS IN HEALTH STATUS ACROSS A CENTURY OF U.S. BIRTH COHORTS

Following decades of improvement in functioning and a decline in disability among the U.S. population aged 65 or older, newer cohorts approaching middle-age (ages 40–59) and “young old” (ages 60–69) began to experience increasing functional limitations and disability starting in the late 1990s. The worsening disability trend is accompanied by increasing mortality rates in middle age around the early 2000s, which were thought to be driven by rising “deaths of despair” (drug-, alcohol-, and suicide-related mortality) combined with slowdowns in progress in heart disease mortality. Suicide, cirrhosis of the liver, and fatal drug overdoses suggest that victims are likely suffering from psychological distress. The rising mortality rate narrative initially was only applied to the White population. Subsequent research, however, suggests it is not restricted to that population subgroup.

According to an article appearing in the November 2021 issue of the American Journal of Epidemiology, important research gaps remain. An example is that studies only look at the end of the morbidity process, which begins for populations with the physiological dysregulation (PD) indicated by a number of biological risk factors and followed by subsequent diagnosis of diseases, functioning loss, disability, frailty, and death. Mental illness (e.g., anxiety and depression) and health behaviors also precede the onset of disability and mortality. Thus, it is essential to investigate whether the unfavorable trend in morbidity and mortality in recent decades should be attributed to health behavior changes driven by psychological distress, deterioration of innate physiological functioning, or both. As a means of addressing various gaps, a comprehensive investigation is described of the trends of physiological status, mental health, and health behaviors by race and sex across a century of birth cohorts that were classified on the basis of nine generations. These researchers found that the worsening physiological and mental health profiles among younger generations imply a challenging morbidity and mortality prospect for the United States, one that might be particularly inauspicious for Whites.

OBTAINABLE RESOURCES

Annual Report To The Nation On The Status Of Cancer

Part 1 of the latest Annual Report to the Nation on the Status of Cancer was focused on national cancer statistics and it became available on July 8, 2021. Part 2, appearing October 26, 2021, in JNCI: The Journal of the National Cancer Institute, is the most comprehensive examination of patient economic burden for cancer care to date and includes information on patient out-of-pocket spending by cancer site, stage of disease at diagnosis, and phase of care. While this analysis is about the costs that are directly incurred by patients, which are critical to patient finances, the total overall costs of cancer care and lost productivity in the United States are much larger. Among adults aged 65 years and older who had Medicare coverage, average annualized net out-of-pocket costs for medical services and prescription drugs, across all cancer sites, were highest in the initial phase of care, defined as the first 12 months following diagnosis ($2,200 and $243, respectively), and the end-of-life phase, defined as the 12 months before death among survivors who died ($3,823 and $448, respectively), and lowest in the continuing phase, the months between the initial and end-of-life phases ($466 and $127, respectively). Across all cancer sites, average annualized net patient out-of-pocket costs for medical services in the initial and end-of-life phases of care were lowest for patients originally diagnosed with localized disease compared with more advanced stage disease. Part 1 can be obtained here. Part 2 can be obtained here.

Prison And Jail Reentry And Health

Another section of this month’s edition of the ASAHP newsletter TRENDS discusses incarceration in the context of astrobiology. Mass imprisonment in the United States can be viewed as a public health crisis that has disproportionate negative impacts on communities of color. The reentry population, i.e., individuals released back to the community following incarceration, is sicker than the general population, faces barriers to accessing health care, and often experiences homelessness, unemployment, and a lack of social and family support. A new Health Affairs Policy Brief dives deeper into the link between community reentry and health. The authors provide an overview of research regarding the health outcomes and challenges associated with prior incarceration, a review of strategies currently used to support the health and well-being of the reentry population, and recommendations to improve health and justice outcomes. They indicate that criminal justice reform coupled with targeted upstream efforts, such as investment in criminal justice-based reentry programs; support for communities and the community health systems to which inmates return; and enhanced research evaluation of reentry programming are necessary to mitigate the negative health impacts of mass incarceration. The policy brief can be obtained here.

2020 National Survey Of Drug Use And Health

A first findings report summarizes key findings from the 2020 National Survey on Drug Use and Health (NSDUH) for national indicators of substance use and mental health among individuals aged 12 years old or older in the civilian, noninstitutionalized population of the United States. The findings indicate that among the group aged 12 or older in 2020, 58.7% (or 162.5 million individuals) used tobacco, alcohol, or an illicit drug in the past month (also defined as “current use”), including 50.0% (or 138.5 million) who drank alcohol, 18.7% (or 51.7 million) who used a tobacco product, and 13.5% (or 37.3 million) who used an illicit drug. Among members of the group aged 12 or older, 20.7% (or 57.3 million) used tobacco products or used an e-cigarette or other vaping device to obtain nicotine in the past month. Among adults aged 18 or older, 21.0% (or 52.9 million) had any mental illness (AMI) and 5.6% (or 14.2 million) had serious mental illness (SMI) in the past year. The report can be obtained here.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Suicide Rates By Month And Demographic Characteristics: United States 2020

The November 2021 issue of a report from the National Vital Statistics System refers to provisional numbers of deaths due to suicide by demographic characteristics (sex and race and Hispanic origin), and by month for 2020, and compares them with final numbers for 2019. The overall age-adjusted suicide rate declined 3%, with the decline for females (8%) greater than males (2%). Rates for persons aged 10–34 were higher in 2020 than in 2019, whereas rates for persons aged 35 and over were lower. The increases for those aged 25–34 and the declines for those aged 35–74 were significant. The changes in suicide rates by age between 2019 and 2020 were generally similar for both males and females, although only males had a significant increase at ages 25–34. All race and ethnicity groups for women had declines in age-adjusted suicide rates from 2019 to 2020, although only the 10% decline for non-Hispanic white women was significant statistically.

Access To Care And Mental Health Services By Household Income During COVID, U.S.

Since the start of the COVID-19 pandemic in March 2020, approximately 40% of U.S. adults have experienced delayed medical care. As described on November 9, 2021 online in the journal Health Equity, researchers used the Census Bureau's nationally representative pooled 2020 Household Pulse Survey from April to December, 2020 (N=778,819) to analyze trends and inequalities in various access to care measures. During the pandemic, the odds of being uninsured, having a delayed medical care due to pandemic, delayed care of something other than COVID-19, or delayed mental health care were, respectively, 5.54, 1.50, 1.85, and 2.18 times higher for adults with income <$25,000, compared to those with incomes ≥$200,000, controlling for age, sex, race/ethnicity, education, marital status, housing tenure, region of residence, and survey month. Income inequities in mental health care widened over the course of the pandemic, while the probability of delayed mental health care increased for all income groups.

HEALTH TECHNOLOGY CORNER

Mathematical Model For Checkpoint Inhibitor Therapy In Human Solid Tumors

Checkpoint inhibitor therapy of cancer has led to markedly improved survival of a subset of patients in multiple solid malignant tumor types, yet the factors driving these clinical responses or lack thereof are not known. As reported on November 9, 2021 in the journal eLife, researchers from The Houston Methodist Research Institute and several other institutions developed a mechanistic mathematical model for better understanding these factors and their relations in order to predict treatment outcome and optimize personal treatment strategies. The results have demonstrated reliable methods to inform model parameters directly from biopsy samples, which are conveniently obtainable as early as the start of treatment. Together, these suggest that the model parameters may serve as early and robust biomarkers of the efficacy of checkpoint inhibitor therapy on an individualized per-patient basis. The model could provide a way of identifying patients who will benefit from immunotherapy at an early stage in their cancer treatment.

Effect Of A Diagnosis Of Alzheimer's Disease And Related Dementias On Social Relationships

Although early diagnosis has been recognized as a key strategy to improve outcomes of Alzheimer's disease and related dementias (ADRD), the effect of receiving a diagnosis on patients' well-being is not well understood. A study conducted by investigators at Rutger University that was described on October 14, 2021 online in the journal Dementia and Geriatric Cognitive Disorders addresses this gap by examining whether receiving a dementia diagnosis influences social relationships. Data from the three waves (2012, 2014, and 2016) of the Health and Retirement Study were used as part of this study. Results suggest that receiving a new diagnosis of ADRD may have unintended impacts on social relationships. Practitioners and policymakers should be aware of these consequences and should identify strategies to alleviate the negative impact of receiving a diagnosis of ADRD and methods to mobilize support networks after receiving a diagnosis.

DEVELOPMENTS IN HIGHER EDUCATION

It is not uncommon today to learn of distressful events that are experienced by students enrolled in higher education programs. One example of a negative impact on some individuals is that they complete their formal learning period with a mountain of student loan debt, which is most difficult to repay because of low employment salaries upon leaving the academy. As a consequence, it may be more difficult for them to achieve what their parents were able to accomplish much more easily, such as being able to purchase a home or retire at a relatively early age.

Nonetheless, some benefits of a higher education continue to persist. An infogram developed on November 10, 2012 by the American Council on Education (ACE) reveals that increased annual earnings are available at each level when moving from the category high school diploma or equivalent ($31,956) to the category graduate or professional degree ($75,495). Whereas only 6% of adults holders of a bachelor's degree or higher are less likely to smoke, among the group with a high school diploma or equivalent, that figure is 23%. Adults with a bachelor’s degree or higher (65%) are more likely to meet exercise guidelines than possessors of a high school diploma or equivalent (43%). Moreover, adult degree holders and those with some college, but no degree, represent a larger share of workers (69%) than those with a high school diploma or less (32%).

Impact Burden Of And Solutions For FAFSA Verification

The Free Application for Federal Student Aid (FAFSA) unlocks access to federal financial aid programs, including the cornerstone of need-based aid: the Pell Grant. Millions of postsecondary students complete the FAFSA annually, but a significant portion of them cannot receive their aid without completing an additional, lengthy process called verification to confirm that their FAFSA is accurate. Without completion of this audit-like process, students are unable to access federal financial aid, and in many cases state or institutional financial aid. Verification recently has come under scrutiny for its questionable value to the taxpayer and the burden it places on students and institutions. Concerns include the question, is the burden worth the impact on financial aid offices when one in five financial aid administrators spend at least half their time on the verification process?

The National College Attainment Network (NCAN) and the National Association of Student Financial Aid Administrators (NASFAA) joined together to survey both financial aid administrators as well as college access and success advisers on the impact of verification on their students and their work within this landscape of verification relief and scrutiny. In a paper released by the two organizations in November 2021, an exploration looks at those experiences and offers recommendations to decrease the burden verification places on students and financial aid administrators alike.

CBO Cost Estimates For The Build Back Better Act

The Congressional Budget Office (CBO) was requested by Capitol Hill legislators to prepare a cost estimate for the current version of H.R. 5376, the Build Back Better Act (Rules Committee Print 117-18). Provision of this information likely will affect the vote eventually taken on this bill. Several provisions of this proposed legislation pertain to higher education. Title II, Subtitle A, Part 2 discusses these components of H.R. 5376. One example is increasing the maximum federal Pell Grant for enrollment of students at institutions of higher education. A related aspect involves an increase in these grants for recipients of means-tested benefits.

Another provision focuses on retention and completion grants to enable various eligible entities to carry out specific activities, such as expanding evidence-based reforms or practices to improve student outcomes at institutions of higher education in the State or system of institutions of higher education, and how an eligible entity will sustain such reforms or practices after the grant period ends. Priority will be given to entities that propose to use a significant share of grant funds for groups, such as students of color and low-income students.

HEALTH REFORM DEVELOPMENTS

Health care in this nation is affected by a wide range of social forces, including demographic perturbations. An opinion item published on November 10, 2021 in The Milbank Quarterly discusses some implications of a recent sharp decline in birth rates in the United States. Based on provisional data provided by the National Vital Statistics System in May 2021, the U.S. birth rate dropped 4% in 2020 and already was at a record low before the COVID-19 pandemic. The 2020 birth rate was 55.8 live births for every 1,000 females ages 15-44, trending downward for the sixth consecutive year.

The total fertility rate (TFR), a population statistic that simulates the average number of children females in a birth cohort will have if they go through life with current age-specific birth rates, also is trending downward. The TFR in the United States plummeted from 2.12 in 2007 to a record low of 1.64 in 2020, which is far below the level of 2.1 needed for population stability. When the TFR drops below 2.1 (the break-even replacement level), a population will age dramatically in the absence of immigration. Will such an occurrence pose societal challenges?

A major concern is that the reduced rate contributes to labor shortages and also will increase the population “total dependency ratio,” i.e., the ratio of the number of individuals in age groups not typically in the labor market (0-14 and 65+ years) to the number in all other age groups, multiplied by 100. U.S. Census Bureau data show that the U.S. dependency ratio was 59 in 2010, 64 in 2019, and is projected to be 73 by 2050 primarily due to population aging from the 1946-1964 Baby Boom. Additional declines in birth rates without offsets from immigration will further increase the dependency ratio, which raises serious concerns about economic stability/growth and the ability of the working population to support the social, financial, and health care needs of the dependent population. Policy-makers are faced with the task of devising workable interventions to prevent any deterioration in the nation’s ability to address the population’s health care needs effectively.

Why Measurement Matters In Advancing Health Equity

A blog published on November 2, 2021 by The Commonwealth Fund refers to how the COVID-19 pandemic exposed long-standing racial and economic injustices embedded in the U.S. health care system. One result is a renewed commitment to improve health equity and address the drivers of health (DoH) that account for 80% of health outcomes and have a disproportionate impact on communities of color, including stable, affordable housing; healthy food; reliable income; and interpersonal safety, among other factors. Advancing health equity and addressing DoH will require changing both how and what is measured in health care. Measurement plays a fundamental role because it equips providers with data to identify and address unmet needs, and allows policymakers and payers to account for DoH in payment models.

Despite the well-documented impact of DoH on health outcomes and costs and their impact on people of color, there still are no approved, standardized measures in any Centers for Medicare and Medicaid Services’ (CMS) programs. Although a growing number of CMS Innovation Center models are incorporating DoH screening and navigation on social needs, they use different tools and approaches, which means that CMS cannot systematically compare or use the data. On the positive side, the recently released CMS Innovation Center Strategy Report will require participants in all new models to collect and report beneficiaries’ demographic data and social needs data, when appropriate.

HealthCare.gov Open Enrollment Begins

November 1, 2021 marked the start of the HealthCare.gov Open Enrollment Period. This year, the period has been extended to January 15 to ensure that enough time is available to obtain health insurance coverage. The number of Navigators to assist with the process of obtaining coverage has been quadrupled so that now there are 1,500 of them. As a result of the American Rescue Plan (ARP), coverage also is more affordable. Four out of five individuals can find a plan for $10 or less per month with this newly expanded financial assistance. Additionally, there are more coverage options this season than last, with the average consumer being able to choose between six and seven insurance companies with plan options.

ALLIED HEALTH WORKFORCE DIVERSITY

Health policy discussions often involve topics, such as the need to provide coverage for individuals who either lack adequate health insurance or who have none at all, along with a steady escalation in health care costs. Generally, the health workforce does not attract as much attention. An implicit assumption seems to be that not only are their sufficient numbers of clinicians, educators, researchers, and students wanting to enter the health care realm, but also that there is no difficulty retaining them afterwards. Unfortunately, that ideal state fails to exist. An aging population with a growing number of patients with multiple co-morbidities acting in concert with portions of the health workforce that is moving just as rapidly into old age brackets and also is at risk of diminishing in size because of deaths and retirements. These conditions provide a rationale for the necessity of having policymakers be on the alert to conditions that influence this component of the health care spectrum.

A positive sign in that direction is some legislation pending on Capitol Hill. H.R. 3320, the Allied Health Workforce Diversity Act of 2021, was introduced in the House of Representatives on May 18, 2021. This measure allows the Department of Health and Human Services (HHS) to provide grants to accredited education programs to increase diversity in the physical therapy, occupational therapy, respiratory therapy, audiology, and speech-language pathology professions. Grants may be used to provide scholarships or to support recruitment and retention of students from underrepresented groups. Two days later, this legislation was referred to the Subcommittee on Health of the Committee on Energy and Commerce. Next, on November 4, following subcommittee consideration at a mark-up session, the bill was forwarded to the full committee by voice vote where on November 17, the full committee voted to advance the bill. A related bill, S. 1679, was introduced in the Senate on May 18 and referred to the Health, Education, Labor, and Pensions Committee where it currently sits awaiting further action.

In the event the proposed legislation reaches approval in both the House and the Senate, and is signed into law by President Biden, scholarships or stipends would be provided for: completion of an accelerated degree program; completion of an associate’s, bachelor’s, master’s, or doctoral degree program; and entry by a diploma or associate’s degree practitioner into a bridge or degree completion program. Another provision would furnish assistance for completion of prerequisite courses or other preparation necessary for acceptance for enrollment in the eligible entity; and carry out activities to increase the retention of students in one or more programs in the professions of physical therapy, occupational therapy, respiratory therapy, audiology, and speech-language pathology.

Meanwhile, President Biden signed into law on November 15 the one trillion dollar Infrastructure Investment and Jobs Act (H.R. 3684). The bill was approved by the House on a vote of 228-206, which included 13 Republicans. The Senate approved this legislation in August, with 19 Republicans voting to approve it. The next major legislation on the agenda involves roughly $2 trillion for health care, education and climate-change in what is called the “Build Back Better” reconciliation package. Legislators are waiting for an official Congressional Budget Office (CBO) cost estimate of the bill (H.R. 5376). The CBO is releasing estimates for individual titles of bills as they are completed.

ASTROBIOLOGY AND INCARCERATION

A pair of words characteristically not often found in the same sentence is the science of astrobiology and incarceration. The following comments about both realms is predicated on the assumption that the health status of individuals confined to the nation’s jails and prisons is mostly hidden from general view. Although social debates rage over issues regarding whether punishments that result in incarceration are either too excessive or not harsh enough, a proposition is advanced that insufficient attention tends to be paid to the physical and mental health of the imprisoned subset of the population.

Increases in the older inmate cohort in prisons are attributable in part to a growth in the number of first-time aging offenders, elimination of parole, increased sentence lengths that include life terms, and mandatory minimum sentencing. Moreover, older prisoners require different levels of care due to increased physical and mental comorbidity burden. Compared with their younger counterparts, older incarcerated patients reflect high rates of diabetes mellitus, cardiovascular conditions, and liver disease. Cardiovascular disease is significant because it is a leading cause of death among prisoners. Mental health problems also are common, especially anxiety, fear of death or suicide, and depression. A related concern is that correctional health care, whether provided by the government or the private sector, may not be subject to the same quality standards as the general health care system. Another important consideration is that many prisoners enter the correctional system with pre-existing physical and mental health problems.

According to a paper in the November 2021 issue of the journal Astrobiology, introducing educational programs into prisons has been shown to be beneficial not only for the richness of opportunities offered to prisoners, but also in efforts to reduce crime. An approach to prison education is to ask the question: what features of the prison environment give its inhabitants experience and knowledge that are unique to them and not experienced by members of the non-incarcerated population? If such aspects can be identified, then an opportunity may exist to allow prisoners to use that experience to contribute new ideas to society. Of some interest is that prisons bear similarities to planetary sites in remote locations that include relative isolation and confinement of the enclosed population compared to the external population, where limited interactions occur with participants in the larger outside world. Hence, the incarcerated possibly could be in somewhat of an advantageous position to have a deep intuitive understanding of the challenges of existing in a small relatively isolated population.

An endeavor in Scotland called the Life Beyond project involves the prison population in designing settlements for the planetary bodies Moon and Mars. Apart from improving educational opportunities in prisons, this initiative demonstrates the potential for prisoners to contribute to space settlement by applying their experience of the prison space analog environment. A conspicuous development is how the project rapidly expanded beyond the objective of science and engineering into creative writing, art, music, political philosophy, and other disciplines.

NEW INSIGHTS ON THE DETERMINANTS OF HEALTH TECHNOLOGIES USAGE

The future of health care in society is strongly tied to technology as sensors, wearable devices, and telemedicine continue to shift the health care paradigm. One such technology is the electronic (e-health) health portal, which provides patients with electronic access to their own medical information, allowing them to view their medical records and to interact with their clinicians. Several documented benefits of portal use to both patients and health care personnel have been identified, but adoption continues to lag in comparison with other technologies. The lack of adoption of e-health technologies in any segment of the population (e.g., elderly patients and immigrants) can create wide health care disparities that should be addressed. A study described in the September 2021 Special Issue of the journal Cyberpsychology, Behavior, and Social Networking was aimed at understanding the critical success factors and barriers for e-health portal use.

The researchers investigated the role of information privacy and security, and identified factors that influence the known antecedents of adoption intentions. An analysis of 836 data records showed that while privacy and security concerns have a negative impact on attitudes toward e-health portals, increasing the awareness of privacy and security controls alleviates such concerns. The findings also suggest that individuals worry more about who possesses the right to access their health data (i.e., who, what, when, and why) than the mechanisms used to safeguard data from unauthorized access. The study found that that perceived benefits and support (i.e., emotional and technical support) positively influenced the determinants of use intentions. The implications of these findings for health care providers and policy makers are discussed. For example, health care providers must explain the benefits of e-health portals to individuals adequately to increase their acceptance of e-health portals.

MULTIMORBIDITY FROM THE PERSPECTIVE OF COMPLEXITY SCIENCE

Another section of this issue of the newsletter discusses old age and loneliness. Closely related to those factors is the concept of multimorbidity, the occurrence of two or more long‐term conditions in an individual, which is a major global concern that places a huge burden on healthcare systems, clinicians, and patients. Multimorbidity challenges the current biomedical paradigm, in particular conventional evidence‐based medicine's dominant focus on single‐conditions. Patients' heterogeneous range of clinical presentations tend to escape characterization by traditional means of classification. Optimal management cannot be deduced from clinical practice guidelines. A paper in the October issue of the Journal of Evaluation in Clinical Practice argues that person‐focused care based in complexity science may be a transformational lens through which to view multimorbidity, to complement the specialism focus on each particular disease. Complexity science focuses on understanding, as a contextualized whole, the many parts of multifaceted phenomena. The approach offers an integrated and coherent perspective on an individual's living environment, relationships, somatic, emotional and cognitive experiences, and physiological function.

Providing this integration is an essential task of the generalist, but is it something that all clinicians need to be able to do when managing patients with multimorbidity? The underlying principles include non‐linearity; tipping points; emergence; importance of initial conditions; contextual factors and co‐evolution; and the presence of patterned outcomes. From a clinical perspective, complexity science has important implications at the theoretical, practice, and policy levels. Three essential questions emerge: (1) What matters to patients? (2) How can we integrate, personalize and prioritize care for whole individuals, given the constraints of their socio‐ecological circumstances? (3) What needs to change at the practice and policy levels to deliver what matters to patients? The authors acknowledge that these questions have no simple answers, but complexity science principles suggest a way to integrate understanding of biological, biographical, and contextual factors to guide an integrated approach to the care of patients who experience multimorbidity conditions. Managing these individuals simultaneously can have significant effects on health professionals themselves. It can challenge their: reductionist basic training; individual clinical and interpersonal competence; practice organization; interdisciplinary working styles; and last but not least, stress and burnout, especially when working with members of persistent chronic disadvantaged communities.

OBTAINABLE RESOURCES

Long-Term Services And Supports Needed By Retirees

The goal of a three-part series of briefs from the Center for Retirement Research at Boston College is to help retirees, their families, and policymakers better understand the likelihood that 65-year-olds, over the course of their retirement, will experience disability that seems manageable, catastrophic, or somewhere in-between. The initial brief in June 2021 begins by describing the risk of needing different levels of support during retirement. The first section introduces the analysis. The second section explains the methodology, including how support needs are measured and classified. The third section describes the results: about one-fifth of retirees will need no support and one-quarter are likely to experience the type of severe needs that most patients dread. In between these two extremes, 22% will have low needs and 38% will have moderate needs. The brief can be obtained here.

The second brief in the series was released in September 2021. It explores the extent to which retirees’ financial and non-financial resources together could meet different levels of care needs. The first section provides an overview of the types of care older adults typically receive. The second section explains the methodology for estimating the support that various family members and financial resources can provide. The third section describes the results, and reports that, at age 65, only about one-fifth of retirees have the family and financial resources to cover high intensity care for at least three years and about one third do not have any resources at all. The second brief can be obtained here.

Journals Of Gerontology Scientific Articles On COVID-19

The Gerontological Society of America's highly cited, peer-reviewed journals are continuing to publish scientific articles on COVID-19. The following were published between August 16 and September 21, 2021 in the Journals of Gerontology, Series B: Psychological Sciences and Social Sciences:

COVID-19-Related Worries, Disruptions, And Depressive Symptoms Among Community-Dwelling Older Adults With Disabilities: What Makes The Difference? which discusses how the results supported the claim that the associations between COVID-19-related social disruptions and depressive symptoms can vary over time.

Physical Disability And Older Adults’ Perceived Food And Economic Insecurity During The COVID- 19 Pandemic, which discusses how older adults with more functional limitations were vulnerable to economic and food insecurity during the pandemic.

Changes In Older Adults’ Social Contact During The COVID-19 Pandemic, which discusses the importance of ensuring that communication technologies to maintain social ties are available to and usable by older adults, particularly for those living in residential care settings.

A National Study Of Racial-Ethnic Disparities In COVID-19 Concerns Among Older Americans: Evidence From The Health And Retirement Study, which discusses how more research and policy interventions are needed to lessen the disproportionate burden of COVID-19 experienced by older adults of racial-ethnic minority groups.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Emergency Department Visits Involving Dental Conditions, 2018

Oral health contributes to overall wellbeing and improved quality of life. Untreated poor dental health also can lead to negative general health outcomes. According to a statistical brief published on September 30, 2021 by the Agency for Healthcare Research and Quality, there were two million dental-related emergency department (ED) visits in the U.S. in 2018, accounting for 1.4% of the 143 million total ED visits. The vast majority of dental-related ED visits were treat and release (94.5%), with the remaining ED visits resulting in hospital admission (5.5%). Individuals aged 18–44 years had the highest rate of dental-related ED visits overall (1,107.4 per 100,000 population) compared with all other age groups. The rate of dental-related ED visits was more than 2.5 times higher for non-Hispanic Black individuals than for other race/ethnicity groups (1,362.4 vs. 520.9 or less per 100,000 population). Individuals residing in the lowest income communities (quartile 1) had the highest rate of dental-related ED visits (1,069.1 per 100,000 population).

Health Care Spending For Working Americans

Average annual health care spending for individuals with employer-sponsored insurance (ESI) rose 2.9% to $6,001 per person in 2019, according to the Health Care Cost Institute’s annual Health Care Cost and Utilization Report that was released in October 2021. Between 2015 and 2019 spending increased by 21.8% or $1,074 per person. While prices continued to grow each year, utilization of health care services declined slightly in 2019, leading to slower year-to-year spending growth. The report examines four groups of health care services. Of the four major categories, outpatient visits saw the highest spending increase from 2015 to 2019 (31.4%). Spending per person increased 14.8% over five years for professional services. Spending per person on inpatient admissions rose 14.4% between 2015 and 2019. Increases in prices and use led to a 31.4% increase in outpatient spending over five years. Spending on prescription drugs increased 28.4% over five years. Out-of-pocket spending increased $91 per person over five years.

HEALTH TECHNOLOGY CORNER

Near-Infrared Fluorogenic Spray For Rapid Tumor Sensing

The prognosis for a cancer patient who undergoes surgery is better if the surgeon removes all of the tumor, but it can be hard to tell where a tumor ends and healthy tissue begins. Surgical resection of cancerous tissues is a critical procedure for solid tumor treatment. During the operation, the surgeon mostly identifies the cancerous tissues by naked-eye visualization under white light without aid. The outcome heavily relies on the surgeon’s experience. According to an article published on September 22, 2021 in the American Chemical Society’s journal ACS Sensors, a near-infrared pH-responsive fluorogenic dye, CypH-11, was designed to be used as a sensitive cancer spray to highlight cancerous tissues during surgical operations, minimizing the surgeon’s subjective judgment. This fast-acting spray could be a handy and effective tool for fluorescence-guided surgery, identifying small cancerous lesions in real time for optimal resection without systemic toxicity.

Acupuncture In The Ear To Reduce Pain And Opioid Use For Total Knee Replacement Surgery Patients

Patients who have acupuncture during total knee replacement surgery report less pain and need far fewer opioids to manage their discomfort, according to a study presented in October 2021 in San Diego, CA at the annual conference of the American Society Of Anesthesiologists. Results of the study, which occurred in New York City at the Hospital for Special Surgery, showed that 65% of patients who received acupuncture during surgery achieved a low-dose or opioid-free postoperative experience, compared to 9% of patients outside of the study. All patients received the institution’s standard opioid-sparing multimodal analgesic protocol, with the addition of electroacupuncture, a modified form of traditional acupuncture that applies a small electric current to thin needles that are inserted at known acupuncture points on the body. The acupuncture in this investigation was administered during surgery by a physician who is board-certified in medical acupuncture to eight specific points in the ear to provide targeted pain relief in the knee.

DEVELOPMENTS IN HIGHER EDUCATION

Each edition of this newsletter issued by the Association of Schools Advancing Health Professions (ASAHP) provides information about the two domains of health care and education that are separate from one another in many important respects, but also closely related. The steady aging of the U.S. population is accompanied by increases in the number of patients in the oldest brackets who have co-morbidities. Addressing their health and social-related needs will require an adequate supply of competent, adequately prepared practitioners across a wide range of health professions. The education sphere is keenly involved in the production of teachers, clinicians, and researchers necessary to achieve optimal results. Although a main focus is on what transpires in colleges and universities, other levels involving elementary and high schools play a significant role in determining which students will arrive at the door of health professions academic institutions and be able to thrive in that setting once admitted.

The following discussion looks at some key variables involving the ability of students and their families to pay for that level of education and preparation necessary to begin a career in the health professions; the quality of education at levels below college; and the ability to complete formal education in a reasonable time period. Concerning the latter point, race and ethnicity have a bearing on how long it takes students to complete four-year degree programs. A Digest of Education Statistics from the National Center for Education Statistics has data showing that fewer than 50% of students at four-year colleges graduate within four years, which means that longer periods of time can not only produce higher costs than originally expected, but also delay the start of a career. Significantly, non-white students tend to be more burdened with such problems than what white students experience.

Meeting The Costs Associated With Participating In Higher Education

Tuition and related fees pertaining to functions involving meals and residence on campus are beyond the reach of many families. Depending on the amount of time spent in school and the type of education required to become a health professional, some students will graduate with a debt that may exceed $100,000 (e.g., physicians). The current average is approaching $40,000. At the time of distribution of this issue of the newsletter, the fate of $3.5 trillion social spending legislation in Congress has not been determined yet. One component entails making two years of community college free for all and a related piece is increasing the largest Pell Grant awarded to low-income students by $500. Entrance into some health professions requires only an associate degree. Participation in other professions make it necessary to achieve baccalaureate or even higher degrees. Many students who begin at the community college level manage to have credits transferred to four-year institutions and save money in the process of doing so. Also, nearly a third of students skipped the Free Application from Federal Student Aid or FAFSA® last year, with the form’s complexity posing a major reason why they did so. A step in the right direction is that the consumer banking company Sallie Mae launched a free suite of financial education instruments and planning resources, including a FAFSA support tool that can help families complete the form in minutes, to help students maximize federal financial aid.

Quality Of Education Below The College Level

Many students around the nation are plagued by having to attend public schools where dismally low percentages of youth are able to come even close to achieving proficiency at particular grade levels (4th and 8th grades) in reading, mathematics, and science. Alternatives exist in the form of charter schools and voucher programs that enable low-income parents to meet tuition costs in private institutions. Depending on the political jurisdiction at federal, state, county, and city levels, these options may be resisted fiercely. Regarding the issue of charter schools, according to data collected and analyzed by the National Alliance for Public Charter Schools, during the first full school year of the COVID pandemic, a report released in September 2021 shows that the charter sector is likely to have experienced the largest rate of increase in student enrollment in half a decade. Public charter school enrollment increased during the 2020-2021 school year in at least 39 states, the only segment of the public education sector to grow during the COVID-19 pandemic, according to the data compiled by the National Alliance. All told, nearly 240,000 new students enrolled in charter schools during that period, a 7% year-over-year increase, which likely represents more than double the rate of growth from the prior year.

HEALTH REFORM DEVELOPMENTS

The health sector in the U.S. represents approximately 18% of the world’s largest economy. Given the steady numerical and proportional increase in the number of individuals in this nation who are age 65 and older, many of whom have co-morbidities that are costly to treat, that 18% figure can be expected to continue to inch higher. A complaint issued at regular intervals over the decades is that the health sector consists of too many silos that function independently of one another. An area in which improvements have been made, however, involves interprofessional education and clinical care. The Association of Schools Advancing Health Professions (ASAHP), the proprietor of this newsletter, has played an active role in fostering interprofessional improvements and innovations.

Apart from the silo aspect that characterizes portions of the health sphere, it is worth considering that the health domain is just one of several major silos (e.g., agriculture, housing, and national defense) in the overall economy. These other entities bear directly and indirectly on what transpires in the health area. The cost and availability of healthy foods has a role to play in enhancing individual and community health status. The quality of the housing stock and where it is located in every community around the nation have an impact on health. High rental costs, ability to obtain loans to purchase homes, and the extent of crime in neighborhoods are factors that influence personal health. A defense system capable of detecting and preventing biological warfare launched by other nations is necessary to ward off a threat of future pandemics. From the framework of this larger perspective, listed below are some ingredients of the overall U.S. economy that can influence events that unfold in the health domain.

U.S. Census Bureau Data On Income, Poverty, And Health Insurance

The U.S. Census Bureau announced on September 14, 2021 that median household income was $67,521 in 2020, a decrease of 2.9% from the 2019 median of $69,560. The drop is the first statistically significant decline in median household income since 2011. The total number of individuals with earnings decreased by about 3.0 million, while 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, which is 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. Private health insurance coverage continued to be more prevalent than public coverage, at 66.5% and 34.8%, respectively. Some beneficiaries may have more than one type of coverage during the calendar year. Of the subtypes of health insurance, employment-based insurance was the most common variety, covering 54.4% of the population for some or all of the calendar year.

Employment represents the main source of income for a great many inhabitants of the United States. A recurring fear is that the COVID-19 pandemic has resulted in the permanent elimination of many different kinds of jobs. Depending on an individual’s level of education and job skills, it may be possible to obtain new employment in totally different sectors of the economy, but what happens to everyone who is not so fortunate? Even when public assistance is available, will the newly unemployed be able to obtain the same quality of health care from the same providers they relied upon in the past? Declines in household income can affect the ability to meet out-of-pocket health care expenses for necessary purchases, such as for pharmaceuticals. Although not considered a tax, recent increases in inflation that have occurred in 2021 have led to a dramatic rise in the cost of fuel for motor vehicles. Food costs also have been soaring in recent months. Placing food on the table and filling gasoline tanks needed to commute to the workplace are unavoidable expenses that have the potential to crowd out other necessities, such as health care.

U.S. Health Insurance Market Competition

Seventy-three percent of U.S. commercial health insurance markets are highly concentrated based on guidelines used by the Department of Justice and Federal Trade Commission to assess market competition, according to the latest annual report on health insurance competition by the American Medical Association. In 91% of the 384 metropolitan statistical areas studied, at least one insurer had a commercial market share of 30% or more, and in 46% of MSAs a single insurer’s share was at least 50%. Fifty-four percent of markets that were highly concentrated in 2014 became even more concentrated by 2020. A concern is that these markets are ripe for the exercise of health insurer market power, which harms consumers and providers of care.

FEDERAL BUDGET INITIATIVES AT LOGGERHEADS

As the month of September drew to a close and October began, efforts continued on Capitol Hill to reach agreement on two key pieces of legislation: (1) an infrastructure bill, and (2) a separate social policy and climate bill. A bipartisan group of 69 senators, all 50 Democrats and 19 Republicans, in August 2021 successfully passed a roughly $1 trillion infrastructure package aimed at improving the nation’s roads, bridges, ports, and also expanding broadband Internet access for the population. For example, the current provision of telehealth services to residents of rural areas is hampered by broadband being too narrow. The larger bill has a much bigger price tag and is proving to be more nettlesome from the standpoint of not only its broad aims, but also whether it should be passed separately or at the same time as infrastructure legislation.

Disagreements are of both an inter-party nature between Democrats and Republicans as well as between competing factions in the Democratic party. The desired amount of spending for a social policy bill that has a focus on expanding Medicare to include vision, hearing, and dental care; universal prekindergarten; two free years of community college; and creation of a program encouraging utilities to reduce carbon emissions is $3.5 trillion. That figure is where Republicans part company with the Democrats, indicating that several initiatives not only are wasteful, but even have the potential through proposed tax increases to do substantial harm to the overall economy. Within the Democratic party, conflicts also exist between progressives who favor the $3.5 trillion package and centrists who believe that the projected amount of spending is too high and who also have concerns about the amount of taxation needed to finance proposed undertakings.

Adding to the complexity of the situation is the composition of Congress. Usually, Democrats cannot afford a single defection in a Senate that is evenly split between Democrats and Republicans. Whereas over on the House side of Capitol Hill, a thin majority of Democrats means that a loss of a mere three votes can sink what they hope to achieve. The Senate is of much less concern because of the availability of a process called reconciliation, which could make it possible to approve the social policy and climate bill. Rather than needing 60 votes to achieve passage, a simple majority is all that is necessary. Timing also plays an important role. Progressives have indicated that they will block the infrastructure bill if it arrives on the floor for a vote before agreement has been reached on the proposed $3.5 trillion bill.

Other remedies continue to be recommended. One example is to include more short-term spending in the domestic policy package, which would reduce the overall size of the legislation without having to choose which cuts to make, an option that would allow the possibility of extending programs into the future. A different approach would be to fund a reduced number of programs for the long-term rather than expecting to have enough votes in the future when programs might be cancelled. Also, Senator Bernie Sanders (I-VT) has suggested that Medicare benefit expansion should be accompanied by $1,000 debit cards for individuals based on low-income to access vision, hearing, and dental services earlier than what would be provided by the reconciliation bill (e.g., vision in 2022, hearing in 2023, and dental in 2028).

NEUROBIOLOGY OF LONELINESS

The human heart in conflict with itself and the loneliness of the soul have served as inspiration for various forms of artistic expression throughout the ages. Regarding the latter condition, in popular music a top song in 1969 by the group Three Dog Night was titled, “One Is The Loneliest Number.” That particular numeral posits that an aspect of loneliness is a subjective feeling of being isolated and alone. In a related vein, social isolation is an objective state of having few relationships or infrequent contact with others. Meanwhile, along with many other nations, the United States is undergoing a profound demographic shift in which the size of the population 65 years of age and older, both numerically and proportionately, is increasing at a more accelerated rate than it is for younger age groups.

The National Academies of Science, Engineering, and Medicine published a report in 2020 on social isolation and loneliness among older adults, indicating that approximately 24% of community-dwelling Americans aged 65 and older are considered to be socially isolated. A significant proportion of adults in this country report feeling lonely, that is, 35% aged 45 and older and 43% aged 60 and older. Current evidence suggests that many older adults are socially isolated or lonely (or both) in ways that place their health at risk. Moreover, social isolation significantly increases an individual’s risk of mortality from all causes, a risk that may rival the risks of smoking, obesity, and lack of suitable physical activity. Additionally, loneliness has been associated with higher rates of clinically significant depression, anxiety, suicidal ideation, a 59% increased risk of functional decline, and a 45% increased risk of death. Poor social relationships (characterized by social isolation or loneliness) also have been associated with a 29% increased risk of incident coronary heart disease and a 32% increased risk of stroke.

While acknowledging that loneliness is associated with increased morbidity and mortality, an article published in the October 2021 issue of the journal Neuropsychopharmacology indicates that a deeper understanding of the neurobiological mechanisms that underly loneliness is needed to identify potential intervention targets. Identifying such mechanisms is critical for understanding how loneliness contributes to poor mental and physical health, and for conceptualizing potential pharmacological and neurostimulation targets. This first systemic review of the neurobiology of loneliness shows that despite some mixed evidence, the condition is associated with structural and functional differences in the prefrontal cortex, insula, hippocampus, amygdala, and posterior superior temporal cortex, as well as attentional and visual networks.

Apart from the impact on patients, loneliness also can have a major effect on the health care delivery system as measured by an increased use of inpatient care, more visits to providers, increased re-hospitalizations, and longer lengths of stay. A challenge for providers is to develop effective methods to identify social isolation and loneliness in health care settings and use the findings to target appropriate clinical and public health interventions to individual patients, and to target high-need regions and populations served by a practice or health care system.

HOW JUDGMENTAL OR OFFENSIVE WORDS IN OUTPATIENT NOTES MATTER

Health systems increasingly are offering patients ready electronic access to clinician notes and patients strongly support such practice, citing many potentially important clinical benefits. Allowing patients a window into how clinicians view them and their conditions, however, such notes also may cause patients to feel judged or offended, and thereby reduce trust. A study described in the September 2021 issue of the Journal of General Internal Medicine involved data collected from 22,959 patient respondents in three health systems: Beth Israel Deaconess Medical Center in the Boston area, University of Washington Medicine in Seattle, and Geisinger, a rural integrated health system in Pennsylvania to determine what patients may find judgmental or offensive in their notes.

A thematic analysis had a focus on the following domains: Errors and Surprises, involving descriptions of finding inaccuracies in the record and instances when the note negatively surprised the patient. For example, patients reported feeling judged/offended due to documentation of physical examinations or discussions that the patient believed had not occurred. Labeling, which entailed patients reported feeling judgment/offense when they felt they were labeled by clinicians. Descriptions of obesity were a frequent cause of feeling negatively labeled, as were other personal descriptors such as “elderly,” ”anxious,” “well-groomed,” or descriptions of patients’ emotional demeanor. Disrespect, with some patients feeling disrespected when they perceived their perspective was not recorded, misunderstood, represented incorrectly, or not valued. Among the patient respondents who had read at least one note and answered two questions, 2,411 (10.5%) reported feeling judged and/or offended by something they had read. Individuals who reported poor health, unemployment, or inability to work were more likely to feel judged or offended. Among those patients, 2,137 (84.5%) wrote about what prompted their feelings. Conclusions reached in the study are that content and tone may be particularly important to patients in poor health. Enhanced clinician awareness of the patient perspective may promote an improved health care lexicon, reduce the transmission of bias to other clinicians, and reinforce healing.