OBTAINABLE RESOURCES

Global Roadmap For Healthy Longevity

With unprecedented global aging, societies must undertake all-of-society efforts to maximize the benefits and minimize the burdens of aging populations. The Global Roadmap for Healthy Longevity (Global Roadmap) describes a realistic vision of healthy longevity that could be achieved by 2050. The vision includes full inclusion of individuals of all ages, regardless of health or functional status, in all aspects of society and societies characterized by social cohesion and equity. To achieve the vision, Global Roadmap recommends changes that need to be made to health systems, social infrastructure, physical environments, education, work, and retirement. In some cases, the recommended changes benefit older persons most directly, but when the older portion of the population thrives, members of all ages benefit. If adopted and implemented, the recommendations of this report can support individuals of all ages in all corners of the globe to live long, meaningful, and purpose-driven lives by 2050. The report can be obtained here. 

Treating Older Patients In The Emergency Room 

AARP has teamed up with the Geriatric Emergency Department Collaborative (GEDC) to publish two new videos designed to educate and raise awareness about the serious issues of dementia and delirium in health care settings, particularly emergency rooms. These short educational resources provide action steps for providers, patients, and family caregivers to identify and manage issues related to brain health in the emergency room more effectively. By implementing relatively straightforward and cost-effective measures outlined in the videos, human brain health can be protected and medical outcomes can be improved. The videos are: 

· Dementia in the ED: Providing Better Care for Older ED Patients  

· Delirium in the Emergency Department: Serious, Costly, and Potentially Deadly 

They can be viewed here.  

Annual Report To The Nation On The Status Of Cancer 

Overall cancer death rates continued to decline among men, women, children, and adolescents and young adults in every major racial and ethnic group in the United States from 2015 to 2019, according to the latest Annual Report to the Nation on the Status of Cancer. From 2014 to 2018, overall cancer incidence, or new cases of cancer, remained stable for men and children, but increased for women and adolescents and young adults. This year’s report, published October 27, 2022, in the journal Cancer, also highlights longer-term trends in pancreatic cancer, as well as racial and ethnic disparities in incidence and death rates for many individual cancer sites. The report can be obtained here.  

Improving And Strengthening Employer-Sponsored Health Insurance 

Employer-sponsored insurance (ESI) represents the nation’s largest source of health coverage, but in-depth policy discussion on how to improve the employer system is lacking. With the current policy focus on Medicare, Medicaid, and the individual market, decision-makers are left wanting for ESI-dedicated proposals and analysis. Consequently, both employers and employees need solutions to improve ESI so it can remain in place for the foreseeable future. A new report from the Bipartisan Policy Center discusses this important topic and can be obtained here.

DEVELOPMENTS IN HIGHER EDUCATION

When faced with the daunting task of designing an effective structure for the U.S. government, the founders of this nation envisioned having a legislature to produce laws, a separate executive branch to implement those laws, and an independent judiciary to resolve any differences between them. For the most part, the arrangement functions reasonably well, but not always. An example is when the legislature is unable to reach agreement on a bill that is desired by the chief executive who occupies the White House. Whenever that situation arises, the result can best be described by President Obama who stated, “I've got a pen, and I've got a phone," thereby making it possible to issue executive orders to bypass congressional deadlock.  

It is an effective mechanism, but depending on the nature of that order and how contentious it is, the ruling may not have a long shelf life. For example, once a new president is elected from a different political party, that individual’s first actions might include rescinding a predecessor’s executive orders. A second remedy also is available by having a preliminary injunction granted, which occurred on November 14, 2022 by a three-judge panel of the Eighth U.S. Circuit Court of Appeals. That judicial decision blocks the Biden administration’s plan to cancel some student debt. According to U.S. Secretary of Education Miguel Cardona, as of mid-November 2022, more than 26 million borrowers have provided the information needed to process their applications for relief and 16 million applications have been approved and sent to loan servicers to be discharged when allowed by the courts. 

Time will tell whether students will reap the benefit of efforts to improve their financial situation. Focusing on the possibility that debt relief subsequently will go into effect, the U.S. Department of Education on October 31, 2022 released final regulations that streamline and improve the rules for major targeted debt relief programs. The regulations expand eligibility, remove barriers to relief, and encourage automatic discharges for borrowers who are eligible for loan relief because their school closed; they have a total and permanent disability; or their loan was falsely certified. The rules also establish a fairer process for borrowers to raise a defense to repayment, while preserving borrowers’ day in court by preventing institutions of higher education from forcing students to sign away their legal rights using mandatory     arbitration agreements and class action waivers. Finally, the rules help borrowers avoid spiraling student loan balances by eliminating all instances of interest capitalization not required by statute, which occur when unpaid interest is added to a borrower’s principal balance, increasing the total amount that may have to be paid.     

U.S. Supreme Court And College Admissions

The Supreme Court on August 31, 2022 heard several hours of oral arguments in two cases against Harvard University and the University of North Carolina that were brought by Students for Fair Admissions (SFFA) seeking to overturn four decades of precedent allowing the consideration of race in college admissions. Specifically, this group is petitioning justices to overturn a ruling in the case Grutter v. Bollinger, a decision in 2003 that enabled institutions of higher education to use race as part of a holistic review of admissions applications when narrowly tailored. The Court is expected to announce its decision in 2023, perhaps by early June.

Reauthorization Of The Higher Education Act (HEA)

The Higher Education Act of 1965 (P.L. 89-329, as amended), authorizes a broad array of federal student aid programs that assist students and their families with financing the cost of a postsecondary education, as well as programs that provide federal support to postsecondary institutions of higher education (IHEs). The Department of Education administers the programs authorized by the HEA. The most prominent components are the Title IV programs that provide financial assistance to students and their families. The HEA was first enacted in 1965 and has since been amended and extended numerous times. It has been comprehensively reauthorized eight times. The most recent comprehensive reauthorization occurred in 2008 for a five-year period. Whether it will be reauthorized in 2023 is uncertain. This newsletter will keep readers apprised of any developments that unfold.

HEALTH REFORM DEVELOPMENTS

The availability of high quality health care services is a key factor in producing satisfactory individual and community health status outcomes. A central role in achieving important objectives is played by the health workforce. A problem is that apart from medicine, few professions have data systems that make it possible to enumerate how many students are in the educational pipeline and how many qualified  personnel are in practice, which are determinations required to assess if the workforce matches the health care needs of patients. 

The Bureau of Health Professions (BHPr) in the Health Resources and Services Administration (HRSA) in the U.S. Public Health Service for many years in the 1980s and 1990s made important contributions to efforts aimed at producing an allied health workforce data system. An entity known as the Forum on Allied Health Data (FAHD) made it possible for data experts from several professions to gather annually to improve the collection and distribution of workforce information. The Association of Schools Advancing Health Professions (known as the Association of Schools of Allied Health Professions in the 1990s) hosted FAHD meetings and was awarded two federal contracts by the BHPr in that decade.  

One project was used to identify workforce data sources extant in federal government agencies (e.g., the Veterans Health Administration, Department of Defense, Indian Health Service, Bureau of Labor Statistics); state and city health departments; and professional organizations. A second project was aimed at developing a Minimum Data Set (MDS) that all of these sources could use to produce comparable kinds of information. The idea was to develop a system that reflected common data elements collected at similar periodic intervals. Unfortunately, that result never was achieved. Although the BHPr continues to receive federal appropriations, no funding is intended specifically for allied health workforce data considerations. Apart from a Bureau endeavor that enabled the Institute of Medicine to host an Allied Health Workforce and Services Workshop in 2011, related substantive efforts have lagged. 

National Health Care Quality And Disparities Report

On a related note, the Agency for Healthcare Research and Quality (AHRQ) has released its 2022 National Healthcare Quality and Disparities Report (NHQDR). It provides policymakers, health system leaders, and the public with a statistical portrait of how effectively the health care delivery system provides safe, high-quality, and equitable care to all Americans. The report’s “Portrait of American Healthcare” offers numerous important insights, including: life expectancy in the United States falls behind life expectancy in similarly developed countries, and the gap has grown since 1980; a shortage of primary care health professionals compromises access to services in more than 60% of U.S. counties; and social determinants of health may have a stronger influence on health outcomes than clinical services provided by health care delivery systems. 

Medicaid Structured Family Caregiving

The National Academy for State Health Policy (NASHP) has released a report, Medicaid Structured Family Caregiving: Enabling Family Members to Make Caregiving Their Primary Focus. This brief is based on research and interviews with state staff and examines how Georgia, Missouri, and South Dakota are using Medicaid-funded structured family caregiving (SFC) services to help older adults stay in their homes. These services consist of a package that supports a patient’s primary caregiver, including payment, training, coaching, respite care and other ingredients. Meanwhile, the QUICK STAT section of this November 2022 issue of TRENDS also has information about caregiver health status. 

Medicare Payment Advisory Commission (MedPAC)

MedPAC met virtually on November 3-4, 2022 to discuss a variety of policy issues, including aligning fee-for-service (FFS) payment rates across ambulatory settings, Medicare policy options for increasing payment to primary care providers, and differences in quality measure performance across Medicare populations. Commissioners analyzed quality measure results for different Medicare fee-for-service beneficiaries grouped by two social risk factors: race/ethnicity categories and income level. Moving forward, these officials will review and discuss the analyses and findings, and provide direction for   future work.

2022 ELECTION DAY ANTE- AND POSTMORTEM

Pundits were out in full force prior to the mid-term election on November 8, 2022. Emboldened by what some of them believed were preeminent concerns among voters, such as inflation, crime on the streets, and a southern border that is not secure, they enthusiastically predicted a “red wave” that would overwhelm Democrats in both the U.S. House of Representatives and the Senate. Unfortunately, these experts were not even close in their prognostications. Democrats not only survived, but even thrived in many states and congressional districts.

The eminent biologist J.B.S. Haldane suggested that there are four stages of acceptance in the advancement of science: 

· This is worthless nonsense. 

· This is an interesting and perverse point of view. 

· This is true, but quite unimportant. 

· I always said so. 

In the segment of the cognoscente known as political punditry, it did not take long after November 8 for the experts to change course rapidly to arrive at the equivalent of Haldane’s Stage 4. Not too surprisingly, they basically claimed to suspect well beforehand what the eventual outcome of the election would be. More importantly, rather than dwell on rear view mirror images, the main weighty intellectual task lies ahead, i.e., to predict what will happen in the upcoming 2024 presidential election by identifying who is going to run, who can win, and what the price of a pound of bananas will be on election day. 

ASAHP’s Executive Director, John Colbert, offered a detailed, comprehensive explanation on October 20, 2022 during a plenary session presentation at the Association’s Annual Conference regarding what to expect on election day—November 8. Not only did he provide forecasts that actually materialized, he also was able to look ahead at some ramifications of what to expect for the 2024 election. For example, one topic of particular interest to the health professions education community is reauthorization of the Higher Education Act (HEA). It was last reauthorized in 2008 for a five-year period.  

If legislative action is taken on the HEA in the 118th Congress that begins in 2023, it can be anticipated that the House and Senate will produce vastly different proposals, with the new House Republican majority focused on blocking the Administration’s proposal to cancel up to $20,000 in student loan debt for certain borrowers, as well as placing a cap on overall student borrowing, eliminating public service loan forgiveness, and requiring institutions to have “skin in the game,” holding them accountable for successful student outcomes. A narrowly divided Senate will require Democrats and Republicans to produce a bipartisan proposal, which in recent Congresses has proven elusive due to disagreements between the parties over both Title IV student financial aid, as well as Title IX protections.

RESOLVING HEALTH CARE AMBIGUITIES

Previous issues of this newsletter have discussed how an inability to arrive at correct definitions of various health disorders and how to diagnose them accurately will compromise the effectiveness of treatments that are administered. The October 2022 edition indicated that many scholars have noted that the concept of stigma is defined inconsistently throughout the literature, and that it is measured with different instruments. Similarly, the July-August 2022 issue pointed out that effectiveness in academic and clinical communication depends upon agreement on what words and concepts denote and on the consequent ability to argue logically and accurately. In the pain medicine literature, for example, unfortunately there are many examples of imprecision and confusion in this respect, including misnomers and fallacies in reasoning.

It is likely that readers of this newsletter at one time or another have experienced a headache. The entire August 2022 issue of the journal Seminars in Neurology is devoted to a discussion of this disorder. According to that publication, the first coherent headache classification is seen in writings dating back to the 1st century AD. More recently, the first significant modern attempt at classifying headache disorders was done by an ad hoc committee of the NIH in 1962. The system created that year relied on accepted ideas about headache diagnostic classes, including “vascular headaches” and “muscle contraction headaches.” Although there was little evidence for these categories, and the diagnostic definitions were vague, that “ad hoc committee” classification system was used worldwide for many years. Ultimately, its shortcomings were felt to be more of a barrier than an asset in developing a useful tool for both research and clinical needs.

Defining the epidemiology of headache disorders is challenging given the prevalence of stigma and other harmful misconceptions about these diseases. Understanding the widespread impact of such disorders is essential when considering social and policy interventions to mitigate their impact on health status. Tension-type headache still is considered the most common primary headache disorder, but population-based estimates of its prevalence vary widely. Migraine remains the most common headache disorder in patients who receive clinical care. Prevalence estimates have remained fairly stable over the last two decades, with a one-year period prevalence in the U.S. of 18% of women and 6% of men. Studies in the U.S. also show an inverse relationship between income level and migraine incidence and prevalence, particularly for chronic migraine. Factors mediating this relationship are difficult to define.

The burden of migraine is enormous. The Global Burden of Disease study indicates migraine is the number one cause of disability in women younger than 50 years of age and the number two or three cause of disability worldwide. Further study is needed into underdiagnosis, undertreatment, and persistent stigma associated with headache disorders, especially in underserved communities. Headaches constitute just one more health problem where more clarity and less ambiguity are needed.

DEVELOPMENTS IN HIGHER EDUCATION

Given the contentious nature of legislation that is enacted into law and also in rules finalized by agencies in the executive branch of the federal government, a plausible subheading for many of these initiatives might be “The Attorneys, Accountants, and Public Relations Organizations Relief Act of (fill in the year).” The government has developed an effective means of guaranteeing life-time job opportunities in the private sector for individuals willing to engage in this form of employment. For example, the deadline for submitting comments on a proposed rule to amend regulations implementing Title IX of the Education Amendments of 1972 closed on September 12, 2022. More than 235,000 were submitted. Just think of how many staff in commercial firms were involved in generating these comments on behalf of special interest group clients. Next, the Department of Education will review this huge volume of correspondence before releasing a final set of regulations. A companion thought worth pondering is how many Department personnel will need to be engaged in what can be expected to be a highly time-consuming operation of reviewing those Title IX comments. Whatever the eventual outcome, it is likely that the courts will be kept busy as opponents seek to have findings overturned.

If matters on the litigation front ever seem to become too quiescent, immediate assistance always is just a short distance away. As an illustration, on August 24, 2022 President Biden announced that he would cancel up to $10,000 in student debt for borrowers making under $125,000 a year, with up to $20,000 in relief for Pell Grant recipients. The U.S. Department of Education on September 29, 2022 released its estimate of the costs of this plan, indicating that it will cost an average of $30 billion a year over the next decade. The Administration points out that debt relief is designed to help borrowers and families most in need as they prepare to resume student loan payments in January 2023, with nearly 90% of relief dollars going to those earning less than $75,000 per year. Not surprisingly, opposition already is underway as lawsuits against the proposal are being filed. Among the concerns are that student debt relief will harm a state’s economy by reducing taxes collected and increasing inflation. On a more personal level, some individuals feel aggrieved because they already have worked diligently to pay off their educational debt and do not qualify for financial assistance while others who originally elected not to go to college view it as a handout at the expense of taxpayers.

 Primary Sources Of Tenure Track Faculty Members

Institutions of higher education in the U.S. hire most of their tenure-track faculty members from the same handful of elite institutions, according to a study published in the journal Nature on July 21, 2022. The finding suggests that prestige is overvalued in hiring decisions and that academic researchers have little opportunity to obtain jobs at institutions considered more elite than the ones at which they were trained. Specifically, the study reveals that just 20% of PhD-granting institutions in the United States supplied 80% of tenure-track faculty members to institutions across the country between 2011 and 2020. No historically Black colleges and universities (HBCUs) or Hispanic-serving institutions (HSIs) were among that 20%. One in eight U.S.-trained tenure-track faculty members obtained their PhDs from just five elite schools: the University of California, Berkeley; Harvard University; the University of Michigan in Ann Arbor; Stanford University; and the University of Wisconsin–Madison.

Exploring The Exodus From Higher Education

Enrollment in education after high school is falling significantly at a time when the economy is demanding more educated workers. It is important to understand why students are not attending or staying in college so that institutional leaders and policymakers can adopt policies and practices that meet more of the situations facing today’s students. HCM Strategists and Edge Research, on behalf of the Bill & Melinda Gates Foundation, were partners in conducting an in-depth analysis of current and former students’ attitudes about pursuing education after high school to understand better what is influencing these           students’ perceptions and plans regarding post-high school education. Among the major findings is that although dollars and debt are significant barriers, multiple factors affect this audience’s ability and interest in obtaining a degree. Individuals express limited life satisfaction, and many note they could not manage the stress/challenges associated with college. Addressing financial burdens alone is not a solution. 

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Numbers And Rates Of Suicide By Month And Demographic Characteristics: U.S., 2021

Suicide is a major contributor to premature death in the United States, especially among individuals aged 10 to 34, for whom it is the second leading cause of death. In this country, suicide increased 35% from 1999 to 2018 before declining by 5% through 2020. Despite the overall recent decline, rates continued to increase among females aged 10–24 and among males aged 10–44 and 75 and over. The increase in the number of suicides was greater for males (4%) than females (2%), with the provisional 2021 number for males (38,025) nearly four times that of females (9,621). According to a National Vital Statistics System Release in September 2022, provisional numbers of suicide by month in 2021 are reported and compared with final 2020 numbers, in total, and are presented by sex and age combined. Reporting of suicides in particular can be delayed because of investigations regarding the cause and circumstances surrounding the death. Rates for females are more likely to be incomplete because their deaths more frequently involve drug poisonings.

Associations Of Air Pollution With Body Size And Composition In Midlife Women

A study was done of longitudinal associations of air pollution exposure, including fine particulate matter, nitrogen dioxide, and ozone with weight, BMI, waist circumference, fat mass, lean mass, and proportion fat mass in midlife women. According to a description of research published on September 9, 2022 in the journal Diabetes Care, analyses provide evidence that exposure to these environmental factors is associated adversely with body composition, including higher fat mass, higher proportional fat mass, and lower lean mass, highlighting their potential contribution to obesity. In this prospective cohort study of 1,654 midlife women representing diverse racial/ethnic groups, exposure to air pollution was associated with adverse changes in body composition measures. In particular, particulate matter and nitrogen dioxide were associated positively with fat mass and proportion fat mass, and inversely associated with lean mass. Ozone was associated positively with proportion fat mass and inversely associated with lean mass.

HEALTH TECHNOLOGY CORNER

 Understanding Canine Diseases To Save Human Lives

Dogs develop diseases similar to those of humans. Their inbred genetics makes them a useful model for disease biology, allowing the development of new therapies for veterinary and human use. Inside the cancer center at the Virginia Tech Carilion Health Sciences and Technology campus, equipment, along with much of the building, is shared between veterinary patients and humans participating in clinical trials where dogs and humans can be treated side by side. According to an article published in the September 2022 issue of the journal Nature Medicine, dogs share the human environment and are prone to experiencing many of the same diseases as humans, which means that studying conditions, such as cancer in dogs can be used to develop new drugs for both species. Beyond tapping into the increasingly lucrative global veterinary medicine market (valued at U.S. $29.4 billion in 2021), researchers hope these efforts can improve the health of both pets and their human companions.

The Effect Of Expressive Writing On Wound Healing

Expressive writing is an intervention whereby individuals typically write for 20 minutes a day for three consecutive days about their deepest thoughts and emotions regarding a previous traumatic event or stressor. This activity has been found to be beneficial not only for self-reported health, psychological well-being, and general functioning, but also for immunological function. As described in a paper in the October 2022 issue of the Journal of Psychosomatic Research, investigators studied whether the content (expressive vs control) and timing (pre- vs post-wounding) of a writing task affect the activation of different cell types in the healing skin. The findings showed main effects of both timing and content, whereby those who wrote on either topic pre-wounding had a higher infiltration of Langerhans cells in the epidermis of the healing skin at day 14 compared to those who wrote post-wounding. These particular cells are critical for wound healing because they facilitate transitions between wound healing stages.

OBTAINABLE RESOURCES

Artificial Intelligence In Health Care

Each year, medical diagnosis errors affect the health of millions of Americans and cost billions of dollars. Machine learning technologies can help identify hidden or complex patterns in diagnostic data to detect diseases earlier and improve treatments. A report from the U.S. Government Accountability Office (GAO), the congressional watchdog agency, identified such technologies in use and development, including some that improve their own accuracy by learning from new data. Developing and adopting these technologies has challenges, however, such as the need to demonstrate real-world performance in diverse clinical settings. GAO policy options, like improving data access and collaboration, may help address challenges. Several machine learning (ML) technologies are available in the U.S. to assist with the diagnostic process. The resulting benefits include earlier detection of diseases; more consistent analysis of medical data; and increased access to care, particularly for underserved populations. GAO identified a variety of ML-based technologies for five selected diseases: certain cancers, diabetic retinopathy, Alzheimer’s disease, heart disease, and COVID-19 with most technologies relying on data from imaging such as x-rays or magnetic resonance imaging (MRI). These ML technologies have generally not been widely adopted. Academic, government, and private sector researchers are working to expand the capabilities of ML-based medical diagnostic technologies. The report can be obtained here.

National Strategy To Support Family Caregivers

A report that recently was released is entitled, the 2022 National Strategy to Support Family Caregivers. It provides detailed information about nearly 350 actions federal agencies will take over the next three years to support the nation’s 53 million family caregivers. The National Strategy includes more than 150 actions that state and local governments, public health departments, philanthropies, and community-based, faith-based, and nonprofit organizations should take, recognizing that all these groups have a fundamental role to play in supporting family caregivers. The National Strategy was created to support family caregivers of all ages, from youth to grandparents, and regardless of where they live or what caregiving looks like for them and their loved ones. It was developed jointly by the advisory councils created by the RAISE Family Caregiving Act (P.L. 115-119) and the Supporting Grandparents Raising Grandchildren Act (P.L. 115-196), with extensive input from the public, including family caregivers and the individuals they support. It will be updated in response to public comments and will evolve with the caregiving landscape. A 60-day comment period opened on October 1, 2022. The report and the opportunity to submit comments are here.

Accelerating The Use Of Findings From Patient-Centered Outcomes Research

Patient-centered outcomes research (PCOR) studies consider the questions and outcomes that are meaningful to patients to compare the effectiveness of different prevention, diagnostic, and treatment options. PCOR also increases patient involvement in their care by providing them an opportunity to evaluate the quality, outcomes, and effectiveness of health care treatments and interventions, especially in areas where there is poor existing clinical evidence. The National Academies of Sciences, Engineering, and Medicine Board on Healthcare Services hosted a series of public workshops to explore ways of accelerating the use of PCOR findings in clinical practice to improve health and health care. Workshop discussions touched on the role of community health workers in helping care providers see and understand the whole picture of patient lives, the need for community engagement to ensure research is conducted and applied to practice equitably, and ways of measuring the impact of efforts to disseminate and implement new practices based on PCOR. This report summarizes the discussions that took place at these workshops. The document can be obtained here.

NORMAL BLINDNESS: LOOKING BUT FAILING TO SEE

Looked But Failed to See (LBFTS) errors occur when observers fail to notice a clearly visible item. They can happen across a wide range of tasks and settings, from driving and medical image perception to laboratory visual search tasks, overlooking typos in a paper, or failing to see a cyclist in an intersection. LBFTS can be thought of as a form of “normal blindness.” Although obviously far less severe than clinical blindness, it is so universal that its costs are substantial at a societal level. An article published in the September 2022 issue of the journal Trends in Cognitive Sciences outlines a new, unified account of such errors, arguing that processes that function well in most situations are guaranteed to produce a steady stream of LBFTS errors under some circumstances. The authors advance the proposition that normal blindness is the by-product of the limited-capacity prediction engine that is the human visual system. Processes that evolved to allow individuals to move through the world with ease are virtually guaranteed to cause missing certain significant stimuli, especially in important tasks like driving and medical image perception.

Although various LBFTS situations may seem like distinct phenomena, it can be argued that based on recent work, they all can be seen as products of the same normal mechanisms of attention and object recognition. Specifically: (i) observers only select a subset of what they could process on each fixation (although they are not blind to the rest of the visual input); (ii) even the items that are selected by attention will be missed if too little time is given to their processing; (iii) the processes that give rise to routine visual awareness persuade us that we have seen more than we have actually seen; and (iv) attentional guidance (attentional set) can guide observers away from targets as well as toward them. Taken together, these factors produce a state of ‘normal blindness’ that has significant implications. A framework is shown in which multiple types of LBFTS errors arise from the same underlying processes. A relatively complex task is used in the form of a cartoon as an example. 

ETHICS AND EPISTEMOLOGY OF EXPLANATORY AI IN HEALTH CARE

Artificial Intelligence (AI) is believed to have the potential to produce radical changes in health care. Systems aim to improve diagnosis, prediction, and treatment of a wide array of health conditions. An assumption is that AI will enable more accurate and efficient ways to diagnose diseases and to restore the precious and time-honored connection and trust, i.e., the human touch, allowing health care professionals to spend more time with their patients. Meanwhile, according to a manuscript published in the December 2022 issue of the journal Ethics and Information Technology, sophisticated self-learning AI systems that do not follow predetermined decision rules, often referred to as black-boxes, have spawned philosophical debate. This black-box nature is believed to be a major ethical challenge for the use of these systems and it remains disputed whether explainability is philosophically and computationally possible.

Among various observations made, the authors point out that regarding the possibility of explanations of AI, there is a diversity of answers coming from the fields of computer sciences, philosophy, and the sciences (e.g., biology, medicine, chemistry). In the field of molecular biology, for instance, mechanistic explanations describing the behavior of the underlying mechanisms of real-world phenomena are standard. If the same explanatory logic is applied to AI, however, then it is much more difficult to uphold claims of genuine explanatory success. A claim is acknowledged that explanations of phenomena predicted by AI are unforthcoming due to the lack of causal relations underlying the model predictions. The problem stems from the fact that AI systems involve searching for (high) correlations between features in the data, but it is done without a theoretical backup to provide causal relations. Also, a concern has been expressed in a two-fold argument about a fully-automated explanation in the context of medicine. Medical AI delivers classifications, but classifications are not explanations. Additionally, an explanation requires a bona fide structure for that explanation. Reference also is made to many remaining questions that allude both to epistemologists and ethicists: Should explainability play a role, and if so, which role, in the responsible implementation of AI in medicine and healthcare?

HEALTH REFORM DEVELOPMENTS

A central aim of governmental efforts to improve individual and community health status in the U.S. is to remove inequities. Many kinds of social determinants influence the extent to which all segments of the population benefit from having equal access to high quality health care services. One factor affecting the ability to obtain services has to do with one’s residential location. For example, a  report issued in September 2022 from the American Hospital Association highlights the variety of  causes that resulted in 136 rural hospital closures from 2010 to 2021, and a record 19 closures in 2020 alone. Many longstanding pressures are involved, such as low reimbursement, staffing shortages, low patient volume, and regulatory barriers, as well as the continued financial challenges associated with the COVID-19 pandemic. The report outlines several pathways for rural hospitals to achieve financial sustainability, including additional federal support, flexible models of care, decreased regulatory  burden, partnership arrangements, and state Medicaid expansion. The AHA also continues to urge Congress to extend the Medicare-dependent Hospital and enhanced Low-volume Adjustment programs, which are set to expire this month. The programs provide vital support for geographically isolated rural hospitals with low patient volumes.  

Apart from having accessibility to hospitals, other examples can be provided about unequal use of health care services. A data brief from the Office of the Inspector General at the Department of Health and Human Services (HHS) in September 2022 reveals that the COVID-19 pandemic created unprecedented challenges for how Medicare beneficiaries access health care. The Centers for Medicare & Medicaid Services (CMS) took a number of actions to expand access to telehealth for Medicare beneficiaries temporarily. More than 28 million, about two in five, Medicare beneficiaries used telehealth during the first year of the pandemic. CMS increased the types of services that beneficiaries could use via telehealth, from 118 to 264 service types. Beneficiaries in urban areas were more likely than those in rural areas to use telehealth. In total, 45% of beneficiaries in urban areas used telehealth during the first year of the pandemic. They accounted for more than 24 million of the 54 million Medicare beneficiaries living in urban areas. In contrast, just 33% percent of beneficiaries in rural areas used telehealth. They accounted for more than three million of the more than 11 million Medicare beneficiaries living in rural areas. Reasons for this disparity pertain to rural populations being less likely than residents in urban areas to have access to broadband connectivity. Rural health care providers also may face challenges providing telehealth to their patients because equipment and internet connectivity can be too expensive. 

Poverty And Health Insurance Coverage

The U.S. Census Bureau announced on September 13, 2022 that real median household income in 2021 was not statistically different than 2020. The official poverty rate of 11.6% also was not statistically different between 2020 and 2021. The Supplemental Poverty Measure (SPM) rate in 2021 was 7.8%, a decrease of 1.4 percentage points from 2020. Meanwhile, the percentage of individuals with health insurance coverage for all or part of 2021 was 91.7% (compared to 91.4% in 2020.) An estimated 8.3% of the population, or 27.2 million, did not have health insurance at any point during 2021, according to findings from the 2022 Current Population Survey Annual Social and Economic Supplement (CPS ASEC). That amount compared with an estimated 8.6% of the population, or 28.3 million, who did not have health insurance at any point during 2020. In 2021, private health insurance coverage continued to be more prevalent than public coverage, at 66.0% and 35.7%, respectively. Some individuals may have more than one coverage type during the calendar year. Of the subtypes of health insurance, employer-based insurance was the most common, covering 54.3% of the population for some or all of the  calendar year. 

Constitutionality Of Affordable Care Act Continues To Foster Litigation

A federal judge in Texas agreed this month with plaintiffs that requiring insurers to cover the costs of medications for HIV pre-exposure prophylaxis (PrEP) infringed on their religious rights, effectively eliminating a central tenet of the Affordable Care Act (ACA). Under the ACA, most health plans are required to pay for a range of preventive services. The decision came in response to Braidwood Management v. Becerra (formerly Kelley v. Becerra). Plaintiffs argued that the ACA requirement for insurers to pay for certain preventive services was unconstitutional, because it encouraged behavior that clashed with their personal and religious beliefs, such as  services related to reproductive and sexual health.

OBTAINABLE RESOURCES

Addressing Structural Racism, Bias, And Health Communication Regarding Obesity

The National Academies of Sciences, Engineering, and Medicine's Roundtable on Obesity Solutions convened a three-part workshop series that explored how structural racism; weight bias and stigma; and health communication intersect with obesity, gaps in the evidence base, and challenges and opportunities for long-term, systems-wide strategies needed to reduce the incidence and prevalence of obesity. Through diverse examples across different levels and sectors of society, the workshops explored how to leverage the connections between these three drivers and innovative data-driven and policy approaches to inform actionable priorities for individuals, organizations, and policymakers to make lasting systems change. The workshop report can be obtained at

Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series |The National Academies Press.

The Demographic Outlook: 2022 To 2052

The size of the U.S. population and its age and sex composition affect federal spending, revenues, deficits, debt, and the economy. In a new report, the Congressional Budget Office (CBO) describes its population projections that underlie the baseline budget projections and economic forecast that CBO published in May 2022 and the long-term budget projections that the agency published in July 2022. In CBO’s projections, the population increases from 335 million individuals in 2022 to 369 million in 2052, expanding by 0.3% per year, on average. (In this report, population refers to the Social Security area population—the relevant population for the calculation of Social Security payroll taxes and benefits. The population also is projected to become older, on average, as growth in the number of individuals age 65 or older outpaces that of younger age groups. The civilian noninstitutionalized population grows in numbers in CBO’s projections, from 264 in 2022 to 298 million in 2052. (This measure of the population includes only individuals age 16 or older. The agency uses it to project the size of the labor force.) The prime working age population (ages 25 to 54) grows at an average annual rate of 0.2% over that period, slower than its average over the 1980–2021 period (1.0%). In CBO’s current projections, the population is smaller and grows more slowly, on average, than CBO projected last year. Fertility rates are expected to be lower than the agency projected last year, reducing the size and growth of the population that is under 24 years old over the 30-year projection period. The report can be obtained at

https://www.cbo.gov/system/files/2022-07/57975-demographic-outlook.pdf.

Innovating Undergraduate Education: Lessons From The Pandemic

Innovating undergraduate education must take into consideration the current expectation among college-bound high school students of a return to the traditional. Simply stated, after the challenges of build-the-airplane-while-you-fly-it remote learning and all its attendant problems, students are expecting a return to the face-to-face education of yesteryear.  According to the firm Eduventures, however, the United States is at an inflection point with traditional-aged undergraduate education: Either it is possible to breathe a post-pandemic sigh of relief and go back to an undergraduate education steeped in tradition and circumscribed by the campus and its in-person interactions or a leap can be made to reinvigorate undergraduate education by innovating the experience based on pandemic learnings. The company believes that the latter will help higher education institutions provide relevant education for tomorrow’s so-called “traditional undergraduates.” Ye,t truly innovating undergraduate education requires a considered examination of what pandemic-related technology and pedagogy worked and didn’t work. It also requires a demonstration of value to students who currently yearn for tradition. More information can be obtained at Innovating Undergraduate Education: Lessons from the Pandemic (encoura.org)

HEALTH REFORM DEVELOPMENTS

A central aim of governmental efforts to improve individual and community health status in the U.S. is to remove inequities. Many kinds of social determinants influence the extent to which all segments of the population benefit from having equal access to high quality health care services. One factor affecting the ability to obtain services has to do with one’s residential location. For example, a  report issued in September 2022 from the American Hospital Association highlights the variety of  causes that resulted in 136 rural hospital closures from 2010 to 2021, and a record 19 closures in 2020 alone. Many longstanding pressures are involved, such as low reimbursement, staffing shortages, low patient volume and regulatory barriers, as well as the continued financial challenges associated with the COVID-19 pandemic. The report outlines several pathways for rural hospitals to achieve financial  sustainability, including additional federal support, flexible models of care, decreased regulatory  burden, partnership arrangements and state Medicaid expansion. The AHA also continues to urge    Congress to extend the Medicare-dependent Hospital and enhanced Low-volume Adjustment programs, which are set to expire this month. The programs provide vital support for geographically isolated rural hospitals with low patient volumes. 

Apart from having accessibility to hospitals, other examples can be provided about unequal use of health care services. A data brief from the Office of the Inspector General at the Department of Health and Human Services (HHS) in September 2022 reveals that the COVID-19 pandemic created unprecedented challenges for how Medicare beneficiaries access health care. The Centers for Medicare &   Medicaid Services (CMS) took a number of actions to expand access to telehealth for Medicare beneficiaries temporarily. More than 28 million, about two in five, Medicare beneficiaries used telehealth during the first year of the pandemic. CMS increased the types of services that beneficiaries could use via telehealth, from 118 to 264 service types. Beneficiaries in urban areas were more likely than those in rural areas to use telehealth. In total, 45% of beneficiaries in urban areas used telehealth during the first year of the pandemic. They accounted for more than 24 million of the 54 million Medicare beneficiaries living in urban areas. In contrast, just 33% percent of beneficiaries in rural areas used telehealth. They accounted for more than 3 million of the more than 11 million Medicare  beneficiaries living in rural areas. Reasons for this disparity pertain to rural populations being less likely than residents in urban areas to have access to broadband connectivity. Rural health care providers also may face challenges providing telehealth to their patients because equipment and internet connectivity can be too expensive.

Poverty And Health Insurance Coverage

The U.S. Census Bureau announced on September 13, 2022 that real median household income in 2021 was not statistically different than 2020. The official poverty rate of 11.6% also was not statistically   different between 2020 and 2021. The Supplemental Poverty Measure (SPM) rate in 2021 was 7.8%, a decrease of 1.4 percentage points from 2020. Meanwhile, the percentage of individuals with health   insurance coverage for all or part of 2021 was 91.7% (compared to 91.4% in 2020.) An estimated 8.3% of the population, or 27.2 million, did not have health insurance at any point during 2021, according to findings from the 2022 Current Population Survey Annual Social and Economic Supplement (CPS ASEC). That amount compared with an estimated 8.6% of the population, or 28.3 million, who did not have health insurance at any point during 2020. In 2021, private health insurance coverage continued to be more prevalent than public coverage, at 66.0% and 35.7%, respectively. Some individuals may have more than one coverage type during the calendar year. Of the subtypes of health insurance, employer-based insurance was the most common, covering 54.3% of the population for some or all of the  calendar year.

Constitutionality Of Affordable Care Act Continues To Foster Litigation

A federal judge in Texas agreed this month with plaintiffs that requiring insurers to cover the costs of medications for HIV pre-exposure prophylaxis (PrEP) infringed on their religious rights, effectively eliminating a central tenet of the Affordable Care Act (ACA). Under the ACA, most health plans are required to pay for a range of preventive services. The decision came in response to Braidwood Management v. Becerra (formerly Kelley v. Becerra). Plaintiffs argued that the ACA requirement for insurers to pay for certain preventive services was unconstitutional, because it encouraged behavior that clashed with their personal and religious beliefs, such as  services related to reproductive and sexual health.

DEVELOPMENTS IN HIGHER EDUCATION

Change is a constant feature in the U.S. and the realm of higher education is not immune to experiencing its various effects. Tune in to a college football game this season and note how many times the announcer will state that a particular player is a transfer from another school. The creation of a transfer portal has made it possible for athletes to have the ability to compete elsewhere by seeking to be scooped up by a coach at another institution. During a five-year stay in college, it soon may become commonplace for an athlete to play for four different schools. Another trend that has been in progress for the past two decades is referred to as the “The Great Student Swap.” Related to a skyrocketing increase in tuition fees across the land, students have accumulated $1.7 trillion in debt to meet the costs of participating in higher education. The growth in costs has been accompanied by an expansion in out-of-state enrollment in public             universities. As noted in a report from the Brookings Institution that was issued in September 2022, out-of-state tuition can be twice as high as in-state prices, driving up student debt and university tuition revenue.

Not only has the sticker tuition price difference between in- and out-of-state schools been rising, the share of in-state students is falling. A study referred to in the report argues that many state flagship universities increasingly are unrepresentative of the socioeconomic and racial diversity of the state they serve, in large part because they enroll a growing number of affluent, out-of-state students. This systematic preference for wealth, at times independent of merit, reveals how incentives created by policy decisions and unstable funding streams can distort the enrollment priorities of public universities, with powerful and far-reaching consequences for socioeconomic and racial equality in college access.

COVID-19 Transfer, Mobility, And Progress

Following widespread availability of COVID-19 vaccines in early 2021, officials at many institutions hoped there would be a return to pre-pandemic normalcy in pandemic year 2. Instead, the pandemic      continued to have an impact on transfer pathways, in some cases, at accelerated rates. The COVID-19 Transfer, Mobility, and Progress report series of the National Student Clearinghouse Research Center aims to identify the ways in which the COVID pandemic is changing transfer pathways across higher education. The pandemic’s impacts on transfer enrollment shifted as the pandemic progressed, with transfer pathways and student groups showing diverging patterns over time. The ninth issue in the series became available in September 2022. It summarizes notable changes in transfer enrollment and persistence post-transfer over a two-year period, with results broken out by academic year, student characteristics, and institution type and selectivity. Higher education experienced a total two-year loss of 296,200 transfer students, or 13.5% (nearly 200,000 fewer, or -9.1%, in year 1 and an additional -97,200, or -4.9%, in year 2).

All transfer pathways experienced the impact. Transfer pathways into two-year institutions (reverse      transfer and two-year lateral transfer) experienced double digit rate declines (-21.3% or -113,300 in lateral transfer; -18.0% or -66,900 in reverse transfer). Transfers to four- year institutions also experienced steep declines (-9.7% or -86,000 in upward transfer; -7.6% or -29,900 in lateral transfer). White, Black, and   Native American transfer enrollments all declined precipitously over the last two years (-163,100, -16.4%; -54,800, -16.4%; -3,100, -15.6%, respectively). The pandemic also put older learners at higher risk of    staying out of higher education. Older transfer students (21 or older) declined at more than double the rate of younger students (-16.2% vs -7.2%), and accounted for more than 85% of all transfer declines since the pandemic began (-251K out of -296K).

Proposed Rule On Nondiscrimination On The Basis Of Sex In Education Programs

The deadline for submitting comments on a proposed rule to amend regulations implementing Title IX of the Education Amendments of 1972 closed on September 12, 2022. More than 235,000 were submitted. The Department of Education will review them before releasing a final set of regulations.

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Disparities In Activity And Traffic Fatalities By Race/Ethnicity

Traffic fatalities remain a major public health challenge despite progress made during recent decades. A study described in the August 2022 issue of the American Journal of Preventive Medicine developed exposure-based estimates of fatalities per mile traveled for pedestrians, cyclists, and light-duty vehicle occupants. Exposure to traffic fatality differs by race/ethnicity group and by mode, indicating that adjustment for differential exposure is needed when estimating disparities. The authors found that fatality rates per 100 million miles traveled are systematically higher for Black and Hispanic Americans for all modes and notably higher for vulnerable modes (e.g., Black Americans died at more than four times the rate for White Americans while cycling, 33.71 [95% CI: 21.84, 73.83] compared with 7.53 [95% CI: 6.64, 8.69], and more than two times the rate while walking, 40.92 [95% CI: 36.58, 46.44] compared with 18.77 [95% CI: 17.30, 20.51]). These fatalities are a substantial and preventable public health challenge in the U.S.

Chronic Conditions Among Adults Aged 18─34 Years — United States, 2019

According to the July 29, 2022 issue of Morbidity and Mortality Weekly Reports, in 2019, 53.8% of adults aged 18─34 years had at least one chronic condition, and 22.3% had more than one condition. CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) to measure prevalence of 11 chronic conditions among adults aged 18–34 years overall and by selected characteristics, and to measure prevalence of health-related risk behaviors by chronic condition status. The most prevalent conditions were obesity (25.5%), depression (21.3%), and high blood pressure (10.7%). Differences in the prevalence of having a chronic condition were most noticeable between young adults with a disability (75.8%) and without a disability (48.3%) and those who were unemployed (62.3%) and students (45.8%). Addressing conditions in young adulthood can help slow disease progression and improve well-being across the life span. Coordinated efforts might help improve the availability of evidence-based policies and interventions.

HEALTH TECHNOLOGY CORNER

Pan-Cancer Integrative Histology-Genomic Analysis Via Multi-Modal Deep Learning

The rapidly emerging field of computational pathology has demonstrated promise in developing objective prognostic models from histology images. Most prognostic models, however, either are based on histology or genomics alone and do not address how these data sources can be integrated to develop joint image-omic prognostic models. Additionally, identifying explainable morphological and molecular descriptors from these models that govern such prognosis is of interest. As reported on August 8, 2022 in the journal Cancer Cell, researchers at Brigham and Women’s Hospital in Boston used multimodal deep learning to examine pathology whole-slide images and molecular profile data jointly from 14 cancer types. A multimodal deep learning algorithm is able to fuse these heterogeneous modalities to predict outcomes and discover prognostic features that correlate with poor and favorable outcomes. Investigators presented all analyses for morphological and molecular correlates of patient prognosis across the 14 cancer types.

Effects Of Posture And Gastroparesis On Drug Dissolution In The Human Stomach

The oral route is the most common choice for drug administration because of several advantages, such as convenience and high patient compliance, and the demand and investment in research and development for oral drugs continue to grow. The rate of dissolution and gastric emptying of the dissolved active pharmaceutical ingredient (API) into the duodenum is modulated by gastric motility, physical properties of the pill, and the contents of the stomach, but current in vitro procedures for assessing dissolution of oral drugs are limited in their ability to recapitulate this process. A paper on August 9, 2022 in the journal Physics of Fluids describes how researchers at Johns Hopkins employed a biomimetic in silico simulator based on the realistic anatomy and morphology of the stomach to investigate and quantify the effect of body posture and stomach motility on drug bioavailability. Simulations show that changes in posture can potentially have a significant (up to 83%) effect on the emptying rate of the API into the duodenum.

DEVELOPMENTS IN HIGHER EDUCATION

The higher education realm plays a major role in producing the health workforce. Both the number and kinds of competently-prepared health professionals are dependent on the following considerations: the ability to attract student applicants with a solid background in science and mathematics to a wide range of academic programs at various degree levels, and the resources needed to cover the costs of education in health professions schools. Working Paper No. 30275 that was published in July 2022 by the National Bureau of Economic Research (NBER) sheds light on the latter issue by indicating that an increasing tension between the perceived necessity of a college degree and the challenge of paying for it has led to a proliferation of financial aid policies in the U.S. and around the world. More students are receiving more aid today, and more different types of aid, than ever before. Moreover, half a century of policy experimentation has led to an equally impressive accumulation of research evidence, facilitated by methodological advances and the widespread availability of student-level administrative data.

The authors present the economic rationale for financial aid, a summary of how aid works in the U.S. context, and common methodological challenges in studying it. They review the evidence from both inside and outside the U.S. on the causal impact of a variety of financial aid policies and programs on students’ college decisions, attainment, and post-college outcomes, and summarize the overarching themes with respect to margins of impact, mechanisms, and heterogeneity. They point out in their analysis that seemingly small bureaucratic details can dramatically alter students’ behavioral response to a given dollar of subsidy. Complex and uncertain eligibility and application procedures, such as those historically required to access Pell Grants, can prevent aid from effectively reaching those who most need it. One conclusion reached is the possibility that student aid programs could cause some students harm by inducing them into low-quality institutions when their time might have been better spent in the labor market, or by inducing them to take on debt for programs that don’t pay off.

Government Accountability Office (GAO) Analysis Of Student Loans

When the Patient Protection and Affordable Care Act (ACA) became law in March 2010, several of its provisions involving costs had to be offset. One proposed remedy was to use profits generated by having the federal government take over student lending. Although the Department of Education originally estimated federal Direct Loans made in the last 25 years would generate billions in income for the federal government, its current estimates show these loans will cost the government billions. According to a report issued on July 29, 2022 by the Government Accountability Office (GAO), these loans originally were estimated to produce $114 billion in income for the government. Although actual costs cannot be known until the end of the loan terms, as of fiscal year 2021 these loans are estimated to cost the federal government $197 billion. This swing of $311 billion was driven both by programmatic changes and by reestimates using revised assumptions (e.g., economic factors and loan performance) as additional data became available.

Proposed Rule On Nondiscrimination On The Basis Of Sex In Education Programs

The July 12, 2022 issue of the Federal Register, the official U.S. federal government journal, contains a hefty 190-pages of triple-column text describing a proposed new rule concerning Title IX regulations affecting how campuses deal with sexual harassment, assault, and discrimination. The U.S. Department of Education proposes to amend the regulations implementing Title IX of the Education Amendments of 1972 (Title IX). Current regulations are viewed as not best fulfilling the requirement of Title IX that schools and institutions that receive Federal financial assistance eliminate discrimination on the basis of sex in their education programs or activities. The Department therefore proposes that the current regulations should be amended to provide greater clarity regarding the scope of sex discrimination, including recipients’ obligations not to discriminate based on sex stereotypes; sex characteristics; pregnancy or related conditions; sexual orientation; and gender identity. A comment period ends on September 12, 2022.

HEALTH REFORM DEVELOPMENTS

Health reform is a term that closely relates to the word litigation. For example, UnitedHealth Group (United), owner of the largest health insurance company in the United States, proposes to acquire Change Healthcare (Change), the leading source of key technologies that United’s health insurance rivals depend on to compete with United. A trial in the U.S. District Court in Washington, DC is underway as of August 1, 2022 to prevent the UnitedHealth Group from doing so. The proposed merger is opposed by the U.S. Department of Justice, along with the states of Minnesota and New York, on the basis that it would harm competition in commercial health insurance markets and also in the market for a vital technology used to process claims and reduce health care costs.

By ensuring accuracy, avoiding overpayments, and reducing administrative waste, Change’s technologies save United’s rivals tens of billions of dollars each year and reduce health care costs. Change also has access to vast amounts of competitively sensitive data about United’s rivals, data that reveal how their plans are designed and how they calculate payments to providers, for example, and holds “unfettered” rights to use much of this information.

Constitutionality Of Affordable Care Act Continues To Foster Litigation

The Patient Protection and Affordable Care Act, more commonly referred to as the Affordable Care Act (ACA), became law in March 2010. Since its inception, many ACA provisions have been controversial. The courts have been called upon several times to resolve disputes by litigants. For example, Section 2713 pertains to health insurance coverage of certain preventive services that have been approved by the U.S. Preventive Services Task Force (PSTF), a congressionally established private body of experts; the Advisory Committee on Immunization Practices (ACIP); and the Health Resources and Services Administration (HRSA). As an illustration, opponents of Section 2713 are against the provision of coverage of contraceptives and preexposure prophylaxis (a medication that prevents HIV) on religious or other grounds.

The case Leal v. Becerra filed in December 2020 in federal district court in Amarillo, TX resulted in the rejection of a claim by plaintiffs that 2713 unconstitutionally delegates to HRSA the power to adopt legal requirements binding on private parties, a power the Constitution vests in Congress. In the ongoing case Kelley v. Becerra, plaintiffs appealed this decision to the Fifth Circuit federal court in Fort Worth, TX in February 2021. They challenge the constitutionality of the ACA’s provisions and mandates issued pursuant to this grant of authority to the PSTF, ACIP, and HRSA. Specifically, they object to paying for health insurance plans that cover contraceptives, preexposure prophylaxis drugs, and other preventive-care services for religious reasons plus related preventive-care coverage that they neither want nor need. Instead, all plaintiffs express a desire to purchase on the open market insurance policies that meet their needs and are free from the requirements of the provisions and their resulting mandates.

Enhanced Nursing Home Five-Star Quality Rating System Launched By CMS

The Centers for Medicare & Medicaid Services on July 27, 2022 launched its enhanced Nursing Home Five-Star Quality Rating System, which integrates data these facilities report on their weekend staffing rates for nurses and information on annual turnover among nurses and administrators. The updated Star Ratings increase transparency aimed at improving the quality of nursing homes so residents obtain the reliable, quality care they deserve. CMS research shows that higher nurse turnover is associated with lower quality of care. It is believed that nurses who have worked at a facility longer are more likely to know residents well enough to recognize small health changes and act before they become larger issues. Similarly, administrators with longer tenures help create stable leadership that can lead to more consistent policies and protocols that are tailored to serve residents better. Last January, CMS began posting weekend staffing and turnover rates on Medicare’s Care Compare website. The agency now is incorporating that information into the consumer-friendly Nursing Home Five-Star Quality Rating System. New nurse staffing information includes registered nurses, licensed practical nurses, vocational nurses, and nurse aides who work under the direction of licensed nurse staff and provide much of the day-to-day care for nursing home residents, such as eating, bathing, grooming, and toileting. Ratings are updated quarterly.

MAJOR LEGISLATION ENACTED

The budget reconciliation process was used by the Senate on October 7, 2022 to pass the Inflation Reduction Act. Vice President Kamala Harris cast the tie-breaking 51-50 party-line vote. The House followed suit five days later by passing this $437 billion tax, climate, and health package by a similar party-line vote of 220-207 vote. The legislation was signed into law by President Joseph Biden. A White House celebratory event is scheduled for September 6, 2022.

Apart from health-related provisions, enactment will result in new taxes on large, profitable corporations, increased spending over a decade on new workers and technology at the Internal Revenue Service, and tax subsidies aimed at combating climate change. Some major health features are as follows:

• The Medicare program is granted authority to set the price of certain high-expenditure prescription drugs, in both Part B and Part D. Prices on a narrow set of 10 drugs can be negotiated starting in 2026 with a potential expansion to 20 medicines in 2029.

• Out-of-pocket Part D spending by beneficiaries will be capped at $2,000 per year, beginning in 2025.

• Individuals who received Affordable Care Act subsidies through the 2021 American Rescue Plan will be able to depend on obtaining another three years of those benefits.

• Insulin costs will be capped at $35 per month for Medicare recipients.

• Along with Medicaid program participants, beginning in 2023 seniors will be eligible to receive certain vaccines free.

Apart from the Inflation Reduction Act, the House also approved legislation to extend further Medicare telehealth flexibilities first instituted in response to the COVID-19 pandemic. H.R. 4040, the Advancing Telehealth Beyond COVID-19 Act of 2022 was passed on July 27, 2022. This bill modifies the extension of certain Medicare telehealth flexibilities after the end of the COVID-19 public health emergency. It provides that certain flexibilities continue to apply until December 31, 2024, if the emergency period ends before that date. More specifically, this legislation allows:

• Beneficiaries to continue to receive telehealth services at any site, regardless of type or location (e.g., the beneficiary's home).

• Occupational therapists, physical therapists, speech-language pathologists, and audiologists to continue to furnish telehealth services.

• Federally qualified health centers and rural health clinics to continue to serve as the distant site (i.e., the location of the health care practitioner).

OBTAINABLE RESOURCES

Improving Representation In Clinical Trials And Research

The United States has long made substantial investments in clinical research with the goal of improving the health and well-being of this nation. These investments have contributed significantly to treating and preventing disease and extending human life. Nevertheless, clinical research faces a critical shortcoming. Currently, large swaths of the U.S. population, and those that often face the greatest health challenges, are less able to benefit from these discoveries because they are not adequately represented in clinical research studies. While progress has been made with representation of white women in clinical trials and clinical research, there has been little progress in the last three decades to increase participation of racial and ethnic minority population groups. This underrepresentation is compounding health disparities, with serious consequences for underrepresented groups and for the nation. At the request of Congress, the National Academies of Sciences, Engineering, and Medicine have produced the report, Improving Representation in Clinical Trials and Research: Building Research Equity for Women and Underrepresented Groups. It identifies policies, procedures, programs, or projects aimed at increasing the inclusion of these groups in clinical research and the specific strategies used by those conducting clinical trials and clinical and translational research to improve diversity and inclusion. The report models the potential economic benefits of full inclusion of men, women, and racial and ethnic groups in clinical research and highlights new programs and interventions in medical centers and other clinical settings designed to increase participation. The report can be obtained here.

Financial Barriers Affecting Health Care Habits Of American Men

Compared to men in 10 other high-income countries, men in the United States are more likely to have serious health conditions, die from avoidable causes, and be dissatisfied with the health care system, according to a new Commonwealth Fund study. On nearly every health care measure studied, American men experiencing income insecurity fared the worst. The analysis reveals that U.S. men who have average- or below-average income or deal with frequent financial stress are less likely to obtain preventive care, more likely to have problems affording their care, and more likely to have physical and mental health conditions. These findings track with previous Commonwealth Fund research documenting poor health care access and outcomes for U.S. women of reproductive age. One area in which the U.S. ranked above other countries was the quality of its cancer treatment. Men in the U.S. have the lowest rate of prostate cancer–related deaths. The report can be obtained here.

Digest Of Education Statistics

The National Center for Education Statistics (NCES) on August 9, 2022, released a List of 2021 Digest Tables, a comprehensive statistical reference for all levels of education. The List consists of seven chapters. Information about Postsecondary Education is provided in Chapter 3 and covers several topics including Enrollment Rates (e.g., first-time students and admissions, and racial/ethnic groups); historically Black colleges and universities; faculty salaries and benefits; and degrees conferred at different levels. Chapter 5 contains data on Outcomes of Education (e.g., labor force status by educational attainment; occupation and earnings by educational attainment; and employment by students). The latter item examines the percentage of 16- to 64-year-old undergraduate students employed, by attendance status, hours worked per week, and selected characteristics: 2010, 2015, and 2020. Chapter 6 focuses on International Comparisons of Education (e.g., percentage of degrees at the bachelor's level and above awarded in science and mathematics; information technologies; and engineering, by field of study, level of degree, and country: 2019). The List of 2021 Digest Tables can be obtained here.

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Stress And The Acceleration Of Immune Aging

Stress in the form of traumatic events, job strain, everyday stressors, and discrimination can accelerate aging of the immune system, potentially increasing an individual’s risk of cancer, cardiovascular disease, and illness from infections such as COVID-19. As reported on June 13, 2022 in the Proceedings of the National Academy of Sciences of the USA, a study by researchers at the University of Southern California indicates that exposure to stress is a risk factor for poor health and accelerated aging. Immune aging plays a role in immune health and tissue specific aging, and may contribute to elevated risk for poor health among individuals who experience high psychosocial stress. Individuals with higher stress scores had older-seeming immune profiles, with lower percentages of fresh disease fighters and higher percentages of worn-out white blood cells. The association between stressful life events and fewer ready to respond, or naive, T cells remained strong even after controlling for education, smoking, drinking, BMI and race or ethnicity.

Disparities In Activity And Traffic Fatalities By Race/Ethnicity

Traffic fatalities remain a major public health challenge, A study reported on June 7, 2022 in the American Journal of Preventive Medicine develops exposure-based estimates of fatalities per mile traveled for pedestrians, cyclists, and light-duty vehicle occupants and describes disparities by race/ethnicity, including a sub-analysis of fatality rates during darkness and in urban areas. Exposure to traffic fatality differs by race/ethnicity group and by mode, indicating that adjustment for differential exposure is needed when estimating disparities. Investigators found that fatality rates per 100 million miles traveled are systematically higher for Black and Hispanic Americans for all modes and notably higher for vulnerable modes (e.g., Black Americans died at more than four times the rate for White Americans while cycling, 33.71 [95% CI: 21.84, 73.83] compared with 7.53 [95% CI: 6.64, 8.69], and more than twice the rate while walking, 40.92 [95% CI: 36.58, 46.44] compared with 18.77 [95% CI: 17.30, 20.51]).

HEALTH TECHNOLOGY CORNER

E-Nose Sniffs Out Mixtures Of Volatile Organic Compounds (VOCs)

Clean air and the detection of pollution are of utmost importance for human health. As paint thinner, ink, and adhesives dry, they can release volatile organic compounds (VOCs), which can have a negative impact on health. A typical common air pollutant among these VOCs is xylene, an important chemical feedstock finding widespread use not only in the large-scale synthesis of various polymers, such as polyethylene terephthalate (PET) and parylene, but also in the rubber and leather industries. It exists as three isomers with the same elements, but slightly different arrangements. Because the isomers are so similar, they are difficult to monitor separately. The detection and discrimination of these isomers are quite important for environmental monitoring and medical care. As reported in an article published on June 8, 2022 in the journal ACS Sensors, researchers have developed an electric nose (“e-nose”) with porous metal-organic framework (MOF) films that can distinguish xylene isomer mixtures accurately.

Identification Of A Brain Circuit For Addiction Remission

Drug addiction is a public health crisis for which new treatments are needed urgently. In rare cases, regional brain damage can lead to addiction remission. These cases may be used to identify therapeutic targets for neuromodulation. Substance use disorders in the U.S. are a leading cause of death among young individuals. Treatments such as deep brain stimulation hold promise for helping them overcome addiction, but questions remain about what brain areas should be targeted. Researchers are gaining new insights from patients who are no longer addicted to nicotine after experiencing a brain lesion, such as a stroke. Using a new technique known as lesion network mapping, researchers at Brigham and Women’s Hospital in Boston, MA have mapped addiction remission to entire brain circuits rather than specific brain regions, pointing to new targets for treatment. The results are published on June 13, 2022 in the journal Nature Medicine. A goal is to take larger steps towards improving existing therapies for addiction and open the door for remission.