DATA SHARING AND COMMUNITY RESEARCH PARTNERSHIPS

During the past 20 years, the National Institutes of Health (NIH) has implemented policies designed to improve the sharing of research data. The first requirements were established in 2003. Since then other mandated policies to promote access to research data and resulting findings have been adopted, including in 2022: the NIH public access policy for publications, NIH genomic data sharing policy, and National Cancer Institute Cancer Moonshot public access and data sharing policy. In January 2023, a new NIH data sharing policy went into effect, requiring researchers to submit a Data Management and Sharing Plan in proposals for NIH. It requires consideration of: (1) how data management and sharing are addressed in the informed consent process; (2) limitations on subsequent use of data; and (3) whether access to de-identified data should be controlled. Data sharing policies are predicated on the idea that sharing information is an important component of the scientific method. It enables the creation of larger data repositories to support innovative research questions that may not be possible in individual studies.  

Data sharing allows valuable information to be used for new hypotheses that may extend beyond original plans for the data. It also has been argued that data sharing represents an ethical obligation by possibly maximizing the learning that comes from federal investment in research and from the contributions of volunteer research participants who assume risks for the benefit of scientific discovery. One important question as data sharing is expanded is: “To whom do benefits of data sharing accrue?” An equally important corollary is the question explored in an article published in the May 2023 issue of the journal Social Science & Medicine: “To whom do benefits not accrue?” Data sharing through a community-engaged research lens is examined from the perspective of helping to ensure that the communities that participate in the generation of data receive benefit from the discoveries and knowledge generated. Otherwise, a significant potential for harm can go beyond the common consideration of re-identification, including de-contextualization and misinterpretation of data and resulting findings, and disenfranchisement of participating communities. 

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Adults Who Did Not Take Prescribed Medication In Order To Reduce Costs: U.S. 2021

Data in June 2023 released from the National Center for Health Statistics show that in 2021, 8.2% of adults aged 18–64 who took prescription medication in the past 12 months reported not taking medication as prescribed due to cost. Women (9.1%) were more likely than men (7.0%) to not take prescribed medication. Adults with disabilities (20.0%) were more likely than adults without disabilities (7.1%) to not take medication as prescribed to reduce costs. Adults without prescription drug coverage were more likely to not take medication as prescribed to reduce costs compared with adults with public or private prescription drug coverage. Cost-saving measures included skipping doses, taking less medication than prescribed, or delaying filling a prescription.  Failure to adhere to treatment protocols can pose significant risks that may result in more serious illness and require additional highly costly care.  

Prevalence Of Disability By Occupation Group—-U.S. 2016-2020

Approximately 21.5 million employed U.S. adults aged 18–64 years had some form of disability in 2020. Although 75.8% of noninstitutionalized persons without disability aged 18–64 were employed, only 38.4% of their counterparts with disability were employed. According to the May 19, 2023 issue of Morbidity and Mortality Weekly Reports, individuals with disability have job preferences similar to persons without disability, but might encounter barriers (e.g., lower average training or education levels, discrimination, or limited transportation options) that affect the types of jobs they hold. The highest adjusted disability prevalences were among workers in three of the 22 major occupation groups: food preparation and serving-related (19.9%); personal care and service (19.4%); and arts, design, entertainment, sports, and media (17.7%). Occupation groups with the lowest adjusted disability prevalences were business and financial operations (11.3%), health care practitioners and technicians (11.1%), and architecture and engineering (11.0%).  

HEALTH TECHNOLOGY CORNER 

How Caregiver Speech Can Shape The Infant Brain

Decades of research have established that the home language environment, especially quality of caregiver speech, supports language acquisition during infancy. The neural mechanisms behind this phenomenon remain under studied. An investigation by researchers at the University of Texas at Dallas that was reported in the June 2023 issue of the journal Developmental Cognitive Neuroscience examined associations between the home language environment and structural coherence of white matter tracts in 52 typically developing infants from English speaking homes in a western society. MRI and audio recordings demonstrated that caregiver speech is associated with infant brain development in ways that improve long-term language progress. This study is one of the first to report significant associations between caregiver speech collected in the home and white matter structural coherence in the infant brain and is in line with prior work showing that protracted white matter development during infancy confers a cognitive advantage.  

Enabling Analysis Of Electrocardiograms As Language By A New Deep Learning Approach

Mount Sinai researchers developed an innovative artificial intelligence (AI) model for electrocardiogram (ECG) analysis that allows for the interpretation of ECGs as language. This approach can enhance the accuracy and effectiveness of ECG-related diagnoses, especially for cardiac conditions where limited data are available on which to train. A study published in the June 6 online issue of npj Digital Medicine indicates that this new deep learning model called HeartBEiT forms a foundation upon which specialized diagnostic models can be created. Researchers pretrained HeartBEiT on 8.5 million ECGs from 2.1 million patients collected over four decades within the Mount Sinai Health System. In comparison tests, models created using HeartBEiT surpassed established methods for ECG analysis. HeartBEiT has significantly higher performance at lower sample sizes compared to other models. HeartBEiT also improves explainability of diagnosis by highlighting biologically relevant regions of the EKG vs. standard CNNs.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Work Conditions And Serious Psychological Distress Among Working Adults Aged 18-64

Differences in work conditions, such as job autonomy, job insecurity, and shift work may lead to health disparities in the population. In 2021, working adults aged 18–64 who usually worked the evening or night shift (4.8%) or a rotating shift (3.9%) were more likely to experience serious psychological distress compared with day shift workers (2.3%). According to a Data Brief in April 2023 from the National Center for Health Statistics, the percentage of workers experiencing serious psychological distress increased as monthly variation in earnings increased. Serious psychological distress was higher among workers who reported difficulty changing their work schedule (4.2%) compared with those who reported it was easy or somewhat easy to change their work schedule (2.2%). Adults who worked when they were physically ill in the past three months were more likely to experience serious psychological distress (5.8%) than those who did not work when physically ill (1.9%). 

Chronic Pain Among Adults: United States, 2019-2021

Chronic pain (i.e., pain lasting ≥3 months) is a debilitating condition that affects daily work and life activities for many adults in the United States and has been linked with depression; Alzheimer disease and related dementias; higher suicide risk; and substance use and misuse. The Morbidity and Mortality Weekly Report for April 14, 2023 indicates that during 2021, an estimated 20.9% of U.S. adults (51.6 million individuals) experienced chronic pain, and 6.9% (17.1 million individuals) experienced high-impact chronic pain (i.e., chronic pain that results in substantial restriction to daily activities) with a higher prevalence among non-Hispanic American Indian or Alaska Native adults, adults identifying as bisexual, and adults who were divorced or separated. Clinicians, practices, health systems, and payers should vigilantly attend to health inequities and ensure access to appropriate, affordable, diversified, coordinated, and effective pain management care for all patients. 

HEALTH TECHNOLOGY CORNER 

Smart Surgical Implant Coatings Provide Early Warning And Prevention Of Infection

The prevalence of orthopedic implants is increasing with an aging population. These patients are vulnerable to risks from periprosthetic infections and instrument failures. Both infection and device failure are major problems with orthopedic implants, each affecting up to 10% of patients. Several approaches to fighting infection have been attempted, but all have severe limitations. Newly developed “smart” coatings for surgical orthopedic implants can monitor strain on the devices to provide early warning of implant failures while killing infection-causing bacteria, according to a manuscript published on May 5, 2023 in the journal Science Advances. University of Illinois Urbana-Champaign investigators report that the coatings integrate flexible sensors with a nanostructured antibacterial surface inspired by the wings of dragonflies and cicadas. The coatings prevented infection in live mice and mapped strain in commercial implants applied to sheep spines to warn of various implant or healing failures. 

Can Wearables Capture Well-Being?

Machine learning models applied to physiological metrics collected from wearable devices can have some predictive ability in identifying resilience states and a positive psychological construct. Applying such models, a type of artificial intelligence (AI), to data collected passively from wearable devices can identify a patient’s degree of resilience and well-being, according to investigators at the Icahn School of Medicine at Mount Sinai in New York. Findings reported on May 2, 2023 in the journal JAMIA Open  support wearable devices, such as the Apple Watch®, as a way to monitor and assess psychological states remotely without requiring the completion of mental health questionnaires. Resilience, i.e., an individual’s ability to overcome difficulty, is an important stress mitigator, reduces morbidity, and improves chronic disease management. Digital technology growth presents an opportunity to obtain a better understanding of who is at psychological risk and an improved means of tracking the impact of psychological interventions.  

DEVELOPMENTS IN HIGHER EDUCATION

Not all population subgroups in the U.S. receive equal amounts of attention in policy circles regarding how to cope with various problems that affect individuals within these groupings. An example is the presence of persistent barriers to accessing high-quality, affordable postsecondary education by currently and formerly incarcerated individuals. A positive development is that the U.S. Department of Education has developed a guide to assist colleges and universities in mitigating those barriers, moving beyond the check box on admissions applications, and providing support for these students. An original Beyond the Box report was published in 2016. The newest version, Beyond The Box 2023, became available in April of this year. It incorporates the learning and experience of the past seven years and its content benefits from views expressed by various contributors, such as formerly incarcerated students; leaders of organizations and institutions that work with these individuals; and advocates of criminal justice reform, as well as research and analysis of promising practices.  

Approximately two million Americans are incarcerated and almost 80 million individuals are living with a criminal record, The criminal justice system has a disproportionate impact on people of color and people living in poverty. Education offers a pathway to reenter society successfully, with the knowledge, skills, and credentials to obtain a good job and engage in their community. American postsecondary institutions can provide programs that are inclusive to formerly incarcerated persons. Fair and nondiscriminatory admissions processes have been adopted by many colleges and universities. Seven states have banned the use of criminal justice history questions during the college application process. In 2020, the Common Application, used by more than 900 colleges, removed the criminal justice history question from the common portion of the common application. In 2016, the Second Chance Pell Experimental Sites Initiative was launched, granting access to Pell Grants, a form of federal student financial aid, which opened the doors to higher education for tens of thousands of currently incarcerated students in a pilot program. The success of that initiative has led to forthcoming broad Pell reinstatement for all currently incarcerated students who qualify for federal financial aid and are enrolled in eligible prison education programs,      beginning in July 2023. Despite these important advances, more efforts are needed. The newest Beyond The Box Report lists key recommendations for academic institutions that plan to start or expand programs for these students. 

ASAHP And Third-Party Servicers and Institutions

The Association of Schools Advancing Health Professions (ASAHP) joined forces with several other higher education associations in sending a letter on March 29, 2023 in response to a February 15, 2023 Dear Colleague Letter (DCL), “Requirements and Responsibilities for Third-Party Servicers and Institutions” from the U.S. Department of Education. Given the potential harmful consequences that will result from the Department’s expansive new definition of a third-party servicer (TPS), without corresponding benefit, these organizations urged  the Department to rescind the current DCL and identify alternate approaches that are better targeted to the issues of concern that the government seeks to address.  

Based on comments that were submitted to the Department, it issued an update on April 11, 2023 on Third-Party Servicer Guidance. Specifically, the Department will delay the effective date of the guidance letter, and the September 1, 2023, date no longer will be in effect. The effective date of the revised final guidance letter will be at least six months after its publication to allow institutions and companies to meet any reporting requirements. The Department indicated that it does not consider contracts involving certain activities to constitute third-party servicer relationships, such as study abroad programs, recruitment of   foreign students not eligible for Title IV aid, and clinical or externship opportunities that meet requirements under existing regulations. The Department intends to remove the provision of the guidance document pertaining to foreign ownership of a third-party servicer. That provision was included in guidance issued in 2016 to protect taxpayers from uncollectable liabilities against a foreign owner. Also, public comments will be reviewed carefully on areas of confusion or concern and clarification will be considered about narrowing the scope of the guidance in several areas, including software and computer services; student retention; and instructional content.  

HEALTH REFORM DEVELOPMENTS

Another item in this month’s issue of the ASAHP newsletter highlights the importance that data play in developing effective health policy. Data from the jointly administered federal-state Medicaid program frequently are used to investigate racial and ethnic disparities in health. Unfortunately, there is considerable variation in the completeness of such information across the United States. For example, according to the U.S. Census Bureau, about 19% of Medicaid beneficiaries were missing race/ethnicity information, a rate that varies considerably across states. Approximately one-third of states (18) were missing less than 10% of beneficiaries’ race/ethnicity information. Three states (Nebraska, Rhode Island, and Tennessee) did not have race/ethnicity information for any of their Medicaid beneficiaries.  

To address these gaps, the U.S. Census Bureau’s Enhancing Health Data (EHealth) Program assessed the feasibility, benefit, and effectiveness of linking Medicaid enrollment data (T-MSIS) with Census Bureau microdata (i.e., Decennial Census, American Community Survey [ACS], Census Numident) to enable researchers to document and track racial/ethnic disparities in health more effectively. Also, this research evaluated whether and to what degree bias was introduced into mortality estimates when Medicaid beneficiaries with missing race/ethnicity information were omitted from analysis. Results demonstrate significant potential for using Census Bureau data to complement existing health records that commonly lack important demographic characteristics, such as race/ethnicity. Overall, enhancing this information in Medicaid data with restricted Census Bureau microdata is feasible and can advance an understanding of population health.

Growth In Health Care Costs

In 2020, lower use of health care services led to the first decline in per person health care spending that was seen in 12 years. That decline in utilization, however, was concentrated in the early months of the pandemic. By mid-2020, data from a report in April 2023 from the Health Care Cost Institute, a research group that has partnerships with insurers (CVS Health/Aetna, Humana, and Blue Health Intelligence) to gauge the health care market, show that use (and spending) had largely returned to pre-pandemic levels. In 2021, there was a full rebound in per person health care spending, which was nearly $6,500 (15% higher than in 2020). A 13% increase in utilization from 2020 to 2021 contributed to this growth, following the 7.5% decline in use in 2020. Average prices grew 2% from 2020 to 2021. This lower growth rate than in previous years reflects that the overall mix of care was less expensive in 2021 than in 2020 when many lower cost preventive services were delayed. Overall, prices grew close to 14% over the 2017-2021 period while use grew just over 7%. The largest growth in prices was for inpatient hospital services, which grew 28% even as use declined over the five–year period. Growth in health care prices, and particularly in hospital prices, remains a persistent challenge to access and affordability.  

The Risk Of Losing Health Insurance

Health insurance coverage in the United States is highly uncertain. In the post-Affordable Care Act (ACA), pre-COVID period, it is estimated that while 12.5% of individuals under 65 are uninsured, twice as many are uninsured at some point over a two-year period. Moreover, the risk of losing insurance remained virtually unchanged with the introduction of the landmark ACA according to an article in the May 2, 2023 issue of the journal Proceedings of the National Academy of Sciences of the USA. Data from the Medical Expenditure Panel Survey were used that cover the time period after the landmark Affordable Care Act (ACA) and before the COVID-19 pandemic—from 2014 to 2019—as well as the period 2007 to 2013 prior to the ACA.   

Risk of insurance loss is particularly high for those with health coverage through Medicaid or private exchanges. They have a 20% chance of losing coverage at some point over a two-year period, compared to 8.5% for those with employer-provided coverage. Individuals who lose insurance can experience prolonged periods without coverage. Approximately one-half of them still are uninsured six months later. Almost one-quarter are uninsured for the subsequent two years. Health insurance coverage, whose purpose is to provide a measure of certainty in an uncertain world, is itself highly uncertain. The risk of losing it reduces its value for risk-averse individuals. It also creates the potential for suboptimal medical choices as individuals suboptimally may shift the timing of their medical treatments to align with when they have insurance coverage. 

NECESSITY OF A DEBT LIMIT INCREASE

U.S. Treasury Secretary Janet Yellen has indicated that the federal debt ceiling limit could be reached by June 1, 2023. Action will be necessary to raise that limit. As matters stand in early May 2023, however, President Joseph Biden and congressional Democrats have quite specific views on how to proceed. They favor developing a clean bill involving no restrictions on current federal government expenditures. Led by House Speaker Kevin McCarthy (R-CA), he and his Republican colleagues in that chamber have an entirely different perspective.  

House Republicans on April 25, 2013 introduced the Limit, Save, Grow Act of 2023 (H.R. 2811). It passed the next day on a vote of 217-215. This bill increases the federal debt limit and decreases spending. It also repeals several energy tax credits; modifies the permitting process and other requirements for energy projects; expands work requirements for the Supplemental Nutrition Assistance Program (SNAP) and other programs; and nullifies regulations for the cancellation of federal student loan debt. Specifically, the bill: 

· Suspends the debt limit through March 31, 2024, or until the debt increases by $1.5 trillion, whichever occurs first;

· Establishes discretionary spending limits for the 10-year period FY2024-FY2033 that include decreases in discretionary expenditures;

· Rescinds certain unobligated funds that were provided to address COVID-19 and to the Internal Revenue Service;

· Nullifies certain executive actions and regulations for cancelling federal student loan debt and implementing an income-driven repayment plan for student loans;

· Repeals or modifies tax credits for renewable and clean energy, energy efficient property, alternative fuels, and electric vehicles;

· Establishes new work requirements for Medicaid and expands the work requirements for SNAP and the Temporary Assistance for Needy Families (TANF) program; and

· Requires major federal rules (e.g., rules likely to result in an annual economic effect of at least $100 million) to be approved by Congress before they take effect. 

Two outcomes appear certain. First, the Senate, which is controlled by Democrats, would never include this package. Second, even if they do so, President Biden will not sign it into law. All previous attempts to increase the federal debt level have been successful. Failure to do so might possibly produce some unfavorable results, such as an increase in interest rates, the onset of a recession, and delays in sending monthly checks to Social Security beneficiaries. Higher education also could be impacted adversely, e.g., the student loan repayment pause implemented because of COVID-19 could be ended immediately. 

DATA UNDERGIRD HEALTH POLICY FORMATION

Valid and reliable data are a sine qua non of constructive health policy. A paper in the April 27, 2023 issue of the New England Journal of Medicine on the topic of advances in artificial intelligence for infectious-disease surveillance acknowledged when nurse and statistician Florence Nightingale developed her innovative “rose diagram” of preventable deaths in the Crimean War (April 1854 to March 1855). Despite heavy opposition from her British medical and military superiors, her efforts revolutionized data-driven disease surveillance. An excellent summary of her achievements is conveyed in an article by Lee Brasseur in the Spring 2005 issue of the journal Technical Communication Quarterly. 

Her figures consisted of wedges arranged around a center with each wedge representing by its area the amount of mortality for the period to which it refers. They were called rose diagrams, so called because of their shape, which resembles that flower. The illustrations are remarkable not only in being able to communicate this kind of comparative argument, but also because of their ability to show the progression of the war as revealed both through their circular shape and their textual features. Clearly, nothing like Nightingale’s rose diagram had been seen previously. Not only was her approach unique, it compares favorably with two famous visualizations of that same period: Charles Joseph Minard’s portrayal of wartime mortality while plotting the strength of the Napoleonic Russian Campaign as it progressed through the Russian winter and John Snow’s production of a map displaying epidemiological data leading to the discovery of the source of a cholera epidemic at the famous Broad Street Pump in London, England. 

Many important statistical advances have occurred since then and the U.S. leads the world in the production of important data pertaining to a broad spectrum of human and animal existence. As described in the May 2023 issue of The American Journal of Clinical Nutrition, the 1956 National Health Survey Act authorized federal agencies to collect statistics for a variety of health issues. This law created the U.S. National Health Survey Program, a component of which was the National Health Examination Survey (NHES). Nutritional assessment was added to NHES in 1971 and the survey was renamed NHANES (National Health and Nutrition Examination Survey) to assess health and nutritional status of adults and children in this nation. It operates primarily out of mobile examination centers (MECs) that travel to selected sites to obtain a representative sample of the U.S. population.  

Presently, NHANES is at a key crossroads. The impact of years of inflation on the survey’s stagnant budget has undercut activities to meet the future. The potentially game-changing nature of newer challenges cannot be avoided. Supporters believe that a study by the National Academies of Sciences, Engineering, and Medicine (NASEM) to set the stage for the future of NHANES, i.e., to provide an actionable framework, is a critical and prudent step forward. Also, maintaining the status quo and failing to adapt to emerging challenges cannot be an option for a survey that is so vital to the nation’s health and wellbeing. 

PREPARING THE FEDERAL FY 2024 BUDGET

Fiscal Year 2024 commences on October 1 of this year for the federal government. The stage is set every year by submission of a budget by the president to Congress for its consideration. Regardless of which party controls the White House, legislators in both chambers typically every year see little concordance between what the nation’s chief administrator wants and what eventually will materialize in a final spending package.  

This year may prove to be a faithful rendition of what characteristically unfolds annually. President Biden submitted a budget proposal that is widely viewed as being highly unlikely to reach fruition. Roadblocks occur along the way, deadlines are rarely met, and it is customary each October 1 for a series of short-term resolutions to be created as a means of enabling the government to continue to function. Now that Congress is divided with Republicans controlling the House and Democrats the Senate, the pattern can be expected to manifest itself once again in 2023. The main features of the Administration’s proposed budget include an overall $6.9 trillion that involves a 3.3% increase in defense spending and a 6.5% increase for nondefense discretionary programs, Taxes would be increased by $5.5 trillion and the federal deficit would decline by more than $2 trillion over the next 10 years. The U.S. Department of Health and Human Services would see an 11.5% increase to its overall budget, including $144.3 billion in discretionary and $1.7 trillion in mandatory proposed budget authority.  

The solvency of the Medicare program continues to be worrisome. President Biden proposes to increase the Medicare tax rate from 3.8% to 5% on earned and unearned income above $400,000, and also eliminate a tax loophole that allowed certain business owners to avoid paying Medicare taxes on a portion of their income. A budget element that always attracts much attention is “earmarks.” Legislators are especially fond of them because it makes it possible to spend money on pet endeavors in states and congressional districts that curtail the ability of the Executive Branch to manage the fund allocation process. Representative Robert Aderholt (R-AL), who heads the House Appropriations Labor-Health and Human Services-Education Subcommittee, has decided to ban these congressionally directed spending requests from his panel’s FY 2024 appropriations bill.  

Apart from appropriations, Congress is working on other matters pertaining to health care. One possibility being considered is to prohibit federal agencies from using quality-adjusted life years as a metric to evaluate the cost-effectiveness of drugs and treatments. A concern is that the metric is discriminatory because it undervalues the benefits that therapies provide to individuals who have disabilities. The House Energy and Commerce Committee advanced The Protecting Health Care for All Patients Act (H.R. 485) by a vote of 27-20 along party lines. A concern is that the measure may have the potential to disrupt implementation of the Inflation Reduction Act’s Medicare drug price negotiation provisions.

DEVELOPMENTS IN HIGHER EDUCATION

In his allegorical novel Animal Farm, George Orwell stated that “All animals are equal, but some animals are more equal than others.” The domain of higher education illustrates this maxim all too well. Although some institutions are blessed with thousands of eager applicants each academic year, that luxury does not function across the board of higher education. Based on public polling data, a decline in the number of high school graduates in recent years is an example of a change that has been accompanied by a sentiment, which indicates that some students and their families are less enamored of the value of a college degree than they were only a few years ago. A consequence is that a drop off in the number of applicants at some institutions may result in the necessity of either reducing the number of faculty and staff; eliminating programs in the humanities deemed unlikely to lead to jobs after graduation that are commensurate with the financial costs of obtaining a degree, cutting the scope of campus services offered, or closing the doors completely.

A report issued by the National Student Clearinghouse Center on March 29, 2023 indicates that community college enrollment is starting to grow in spring 2023 (+2.1%), fueled by strong growth among dual enrollees (age 17 and under) and freshmen. Community college growth is occurring across all campus settings while undergraduate enrollment is increasing only at suburban campuses for four-year institutions. Overall undergraduate enrollment was steady this spring (+0.2%), with only the public four-year sector experiencing undergraduate enrollment declines. Total enrollment (graduate and undergraduate enrollment combined) has remained unchanged compared to spring 2022. Enrollment growth continues to be the strongest in certificate programs at both the undergraduate (+5.5%) and graduate (+4.6%) levels. Associate and bachelor’s degree seeking students had more muted enrollment changes (+0.3% and -0.6%, respectively). Undergraduate men, hit particularly hard at the beginning of the pandemic, are now seeing enrollment growth (+0.7%), while the enrollment slide continues for women (-0.9%). Latinx students were the only major racial and ethnic group to show enrollment increases (+0.9%).

Public Hearings On Future Rulemaking Sessions

The U.S. Department of Education (USDE) on March 23, 2023 announced that it will hold virtual  public hearings on April 11, 12, and 13, 2023, to obtain views on future rulemaking sessions. These hearings begin the process of considering new USDE regulations. Following the hearings, an agenda for the rulemaking process will be finalized and nominations for negotiators to serve on the negotiated rulemaking committee will be solicited. The Department is planning three, four-day sessions of negotiated rulemaking to begin this fall. Potential topics for rulemaking are: institutional eligibility, including State authorization; the definition of distance education as it pertains to clock hour programs; and reporting students who enroll primarily online. Individuals who would like to comment at the public hearings must register by sending an email message to negreghearing@ed.gov. Individuals who wish to view the hearings without providing comment must register to observe. The public can provide written comment for 30 days following the official posting.  

Student Loan Forgiveness

Led by Senator Bill Cassidy (R-LA), ranking member for the Health, Education, Labor and Pensions Committee, he and several Republicans in that chamber on March 27, 2023 introduced a Congressional Review Act (CRA) resolution to overturn President Biden’s student loan forgiveness plan, which is under review by the U.S. Supreme Court where a decision is expected to be made in coming months. The plan is aimed at forgiving up to $20,000 for borrowers with federal loans. The Congressional Budget Office estimated that the proposal would cost about $400 billion over the next 30 years. The CRA enables      Congress to review and overturn any regulations created by a federal agency. The Government Accountability Office (GAO) has determined that the plan by President Biden is subject to the resolution. In order for the CRA to go into effect, it will require approval by both the House and the Senate, and then be signed by the President. It is likely that he would veto the initiative if it reaches that stage.

QUICK STAT (SHORT, TIMELY, AND TOPICAL

Maternal Mortality Rates In The United States: 2021

A March 2023 report from the National Center for Health Statistics indicates that in 2021, 1,205 women died of maternal causes in the United States compared with 861 in 2020 and 754 in 2019. The maternal mortality rate for 2021 was 32.9 deaths per 100,000 live births, compared with a rate of 23.8 in 2020 and 20.1 in 2019. In 2021, the maternal mortality rate for non-Hispanic Black (subsequently, Black) women was 69.9 deaths per 100,000 live births, 2.6 times the rate for non-Hispanic White (subsequently, White) women (26.6). Rates for Black women were significantly higher than rates for White and Hispanic women. The increases from 2020 to 2021 for all race and Hispanic-origin groups were significant. Rates increased with maternal age. In 2021, they were 20.4 deaths per 100,000 live births for women under age 25, 31.3 for those aged 25–39, and 138.5 for those aged 40 and over. The rate for women aged 40 and over was 6.8 times higher than the rate for women under age 25.  

Prevalence And Characteristics Of Autism Spectrum Disorder Among Children Aged Eight Years

Data from the March 24, 2023 issue of the Morbidity and Mortality Weekly Report show that for 2020, across all 11 Autism and Developmental Disabilities Monitoring sites, Autism Spectrum Disorder (ASD) prevalence per 1,000 children aged eight years ranged from 23.1 in Maryland to 44.9 in California. The overall ASD prevalence was 27.6 per 1,000 (one in 36) children aged eight years and was 3.8 times as prevalent among boys as among girls (43.0 versus 11.4). Overall, ASD prevalence was lower among non-Hispanic White children (24.3) and children of two or more races (22.9) than among non-Hispanic Black or African American (Black), Hispanic, and non-Hispanic Asian or Pacific Islander (A/PI) children (29.3, 31.6, and 33.4 respectively). ASD prevalence among non-Hispanic American Indian or Alaska Native (AI/AN) children (26.5) was similar to that of other racial and ethnic groups. ASD prevalence was associated with lower household income at three sites, with no association at the other sites.  

HEALTH TECHNOLOGY CORNER 

Breast Cancer Prevention And Screening Recommendations Provided By ChatGPT

Researchers at the University of Maryland School of Medicine in February 2023 created a set of 25 questions related to advice on obtaining screened for breast cancer. They submitted each question to ChatGPT three times to see what responses were generated. ChatGPT provided appropriate responses for most (88%) questions posed about breast cancer prevention and screening as assessed by fellowship-trained breast radiologists. It gave one inappropriate recommendation regarding scheduling mammography in relation to COVID-19 vaccination. Inconsistent responses were found for two questions about breast cancer prevention and screening locations. Although clinically appropriate, recommendations related to screening mammography referenced American Cancer Society guidelines, without mention of the American College of Radiology or the United States Preventive Services Task Force. A description of the study was published on April 4, 2023 in the journal Radiology. 

Gene Editing To Prevent Ventricular Arrhythmias

Human pluripotent stem cell-derived cardiomyocytes (hPSC-CMs) offer a promising cell-based therapy for myocardial infarction, however, the presence of transitory ventricular arrhythmias, termed engraftment arrhythmias (EAs), hampers clinical applications. According to an article published on April 6, 2023 in the journal Cell Stem Cell, researchers at the University of Washington School of Medicine in Seattle have engineered stem cells that do not generate dangerous arrhythmias, a complication that has to date thwarted efforts to develop stem-cell therapies for injured hearts. To create their therapeutic heart cells, the Seattle researchers used pluripotent stem cells. Unlike adult stem cells, which have specialized to become specific cell types, pluripotent stem cells can become any type of cell in the body. From 2012 to 2018 the Seattle team successfully injected pluripotent stem cells into damaged heart walls to create new muscle to replace that lost during an infarction. In animal studies, they showed that the grafted cells would integrate with the heart muscle, beat in synchrony with the other heart cells, and improve the heart’s contractility.  

HEALTH REFORM DEVELOPMENTS

Another item in this month’s issue of the ASAHP newsletter highlights the importance that data play in developing effective health policy. Data from the jointly administered federal-state Medicaid program frequently are used to investigate racial and ethnic disparities in health. Unfortunately, there is         considerable variation in the completeness of such information across the United States. For example, according to the U.S. Census Bureau, about 19% of Medicaid beneficiaries were missing race/ethnicity information, a rate that varies considerably across states. Approximately one-third of states (18) were missing less than 10% of beneficiaries’ race/ethnicity information. Three states (Nebraska, Rhode Island, and Tennessee) did not have race/ethnicity information for any of their Medicaid beneficiaries.  

To address these gaps, the U.S. Census Bureau’s Enhancing Health Data (EHealth) Program assessed the feasibility, benefit, and effectiveness of linking Medicaid enrollment data (T-MSIS) with Census Bureau microdata (i.e., Decennial Census, American Community Survey (ACS), Census Numident) to enable researchers to document and track racial/ethnic disparities in health more effectively. Also, this research evaluated whether and to what degree bias was introduced into mortality estimates when Medicaid beneficiaries with missing race/ethnicity information were omitted from analysis. Results demonstrate significant potential for using Census Bureau data to complement existing health records that commonly lack important demographic characteristics, such as race/ethnicity. Overall, enhancing this information in Medicaid data with restricted Census Bureau microdata is feasible and can advance an understanding of population health. 

Growth In Health Care Costs

In 2020, lower use of health care services led to the first decline in per person health care spending that was seen in 12 years. That decline in utilization, however, was concentrated in the early months of the pandemic. By mid-2020, data from a report in April 2023 from the Health Care Cost Institute, a research group that has partnerships with insurers (CVS Health/Aetna, Humana, and Blue Health Intelligence ) to gauge the health care market, show that use (and spending) had largely returned to pre-pandemic levels. In 2021, there was a full rebound in per person health care spending, which was nearly $6,500 (15% higher than in 2020). A 13% increase in utilization from 2020 to 2021 contributed to this growth, following the 7.5% decline in use in 2020. Average prices grew 2% from 2020 to 2021. This lower growth rate than in previous years reflects that the overall mix of care was less expensive in 2021 than in 2020 when many lower cost preventive services were delayed. Overall, prices grew close to 14% over the 2017-2021 period while use grew just over 7%. The largest growth in prices was for inpatient hospital services, which grew 28% even as use declined over the five–year period. Growth in health care prices, and particularly in hospital prices, remains a persistent challenge to access and affordability.  

The Risk Of Losing Health Insurance

Health insurance coverage in the United States is highly uncertain. In the post-Affordable Care Act (ACA), pre-COVID period, it is estimated that while 12.5% of individuals under 65 are uninsured at a point in time, twice as many are uninsured at some point over a two-year period. Moreover, the risk of losing insurance remained virtually unchanged with the introduction of the landmark ACA according to an article in the May 2, 2023 issue of the journal Proceedings of the National Academy of Sciences of the USA. Data from the Medical Expenditure Panel Survey were used that cover the time period after the landmark Affordable Care Act (ACA) and before the COVID-19 pandemic—from 2014 to 2019—as well as the period 2007 to 2013 prior to the ACA.   

Risk of insurance loss is particularly high for those with health coverage through Medicaid or private exchanges. They have a 20% chance of losing coverage at some point over a two-year period, compared to 8.5% for those with employer-provided coverage. Individuals who lose insurance can experience prolonged periods without coverage. Approximately one-half of them still are uninsured six months later. Almost one-quarter are uninsured for the subsequent two years. Health insurance coverage, whose purpose is to provide a measure of certainty in an uncertain world, is itself highly uncertain. The risk of losing it reduces its value for risk-averse individuals. It also creates the potential for suboptimal medical choices as individuals suboptimally may shift the timing of their medical treatments to align with when they have insurance coverage. 

TECHNOLOGY AND HEALTH CARE

Technological developments have left an enormous imprint on major health care factors, such as cost, quality, and access by patients. A current topic of significant importance is the realm of activity known as artificial intelligence (AI). The various uses of AI in medicine have been expanding rapidly in many areas, including in the: analysis of medical images, detection of drug interactions, identification of high-risk patients, and coding of medical notes. Several such uses are topics in the “AI in Medicine” review article series that had its debut in the March 30, 2023 issue of the New England Journal of Medicine. An aim of the series is to cover progress, pitfalls, promise, and promulgation at the interface of AI and medicine. As a further commitment, a new journal, NEJM AI, will be launched in 2024 to provide a forum for high-quality evidence and resource sharing for medical AI, along with informed discussions of its potential and limitations. 

As a consequence of a substantial investment of money and intellectual effort, computer reading of electrocardiograms (ECGs) and white-cell differential counts; analysis of retinal photographs and cutaneous lesions; and other image-processing tasks has become a reality. Many of these machine-learning–aided tasks have been largely accepted and incorporated into the everyday practice of medicine while the use of AI and machine-learning in medicine has expanded beyond the reading of medical images. AI and machine-learning programs have entered medicine in ways that include, but not limited to, helping to identify outbreaks of infectious diseases that may have an influence on public health; combining clinical, genetic, and many other laboratory outputs to identify rare and common conditions that might otherwise have escaped detection; and aiding in hospital business operations. 

As noted in the NEJM, the use of AI and machine-learning already has become accepted medical practice in the interpretation of some types of medical images, such as plain radiographs, computed tomographic (CT) and magnetic resonance imaging (MRI) scans, and skin images. For these applications, AI and machine-learning have been shown to help health care providers by flagging aspects of images that deviate from the norm. A key question becomes what is the norm? This simple query reveals one of the weaknesses of the use of AI and machine-learning in medicine as it is largely applied today. 

Key concerns requiring a much deeper understanding include how bias in the way AI and machine-learning algorithms were “taught” influence how they function when applied in the real world? How can human values be interjected into AI and machine-learning algorithms so that the results obtained reflect the real problems faced by health professionals? What issues must regulators address to ensure that AI and machine-learning applications perform as advertised in multiple-use settings? How should classic approaches in statistical inference be modified, if at all, for interventions that rely on AI and machine-learning? These problems are among the many that must be confronted. The “AI in Medicine” series can be expected to address these kinds of matters. 

THE ROLE OF EMPATHY IN QUALITY HEALTH CARE

Satisfactory patient care is a core component of quality health care. A positive care experience has occurred when patients report that they experienced what they desired during their interactions with care providers and the system, for example, respectful communication, coordinated care, and timeliness. Positive patient experiences also are important because they are associated with other desirable outcomes, including greater patient adherence to treatment recommendations, better health outcomes, less unnecessary health care utilization, higher staff satisfaction, and better financial performance. As reported in the April 2023 issue of the journal Health Services Research, despite these acknowledged benefits many adults in the United States who visited a doctor report undesirable care experiences. Furthermore, analyses of Centers for Medicare and Medicaid data in 2022 show that only 6% (178) of 3121 hospitals received the highest score of five stars for patient experience. Moreover, this experience particularly is poor for members of minority groups with Black and Hispanic patients relative to Whites having lower scores for person-centered care (26% and 29% of measures lower, respectively) and care coordination (73% and 44% lower, respectively). 

Increasingly, empathy, i.e., understanding and responsiveness to others' thoughts and emotions, is being discussed as a critical contributor to patient experience and patient-centered care. Research on this topic in health care has investigated what facilitates and hinders it, its outcomes, how to measure it, who is (un)likely to display it, and how to improve it. Investigations have produced a large field of information. Unfortunately, it has remained disjointed with little summarizing or integrative work to date, limiting clarity about predictors, outcomes, gaps, opportunities, and intervention effectiveness. A study is described in the aforementioned journal of a systematic review of research on empathy that provides an integrative summary of what is known about predictors and consequences of empathy, methods to study it, and interventions targeting it. The review indicates most studies are survey-based and cross-sectional, empathy predicts health care goals (better outcomes), and five factors predict empathy: provider demographics, characteristics, and behaviors; target characteristics; and organizational context. Analysis of interventions to improve empathy suggests that it can be increased at the individual level via education, but evidence is lacking on organizational-level interventions.

STATE-LEVEL TRENDS IN LIFESPAN VARIABILITY IN THE U.S.

Genetic codes play a highly influential role in human morbidity and mortality, while a case can be made that zip codes also must be taken into account. Where individuals reside has important consequences for their health and well-being. Geographic areas of the U.S. vary on several social, economic, and political dimensions associated with mortality risk. According to an article published in the February 2023 issue of the journal Demography, states are of particular interest because they are semiautonomous units whose governments exert considerable influence over the implementation of policies regarding social service programs and healthcare delivery. Compositional and contextual differences by state contribute to geographic disparities in mortality risk in the United States that are wide, persistent, and potentially growing. For example, life expectancy in 2019 ranged from a high of 80.9 years in Hawaii to a low of 74.4 years in Mississippi. This wide discrepancy among U.S. states exceeds the range in life expectancy among high-income nations. The extent to which differences in lifespan variability by state have changed over time, however, is unclear.  

The study referred to in the aforementioned journal article indicates that lifespan variability declined over time for all states, but sizable disparities remain between states. These differences generally align with states' varied demographic, cultural, and socioeconomic contexts. For instance, southern and Appalachian states experience higher levels of poverty and poor health than other parts of the country. These states exhibit persistently higher levels of lifespan variability. Additionally, states vastly differ in their policy contexts regarding social inequality, such as Medicaid expansion, Earned Income Tax Credit, tobacco control, and setting a minimum wage above the federal level. Policies that alleviate poverty and promote educational and occupational opportunities may be especially effective for averting preventable, early-life deaths that contribute disproportionately to lifespan variability. State policies that curtail early-life mortality would have the dual benefit of increasing life expectancy while simultaneously decreasing lifespan inequality. By adopting more progressive policies found in most low-variability states, high-variability states have the potential to extend the lives of their most vulnerable residents, reduce lifespan variability, and close the population health gaps between the leading and lagging states. Although more research is needed to identify the reasons behind increases in lifespan variability, evidence suggests that rising accidental poisoning and suicide deaths among younger adults are contributing factors.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Emergency Department Visits Related To Mental Health Disorders

A new report from the National Center for Health Statistics (NCHS) describes emergency department (ED) visits related to mental health disorders among adults and assesses differences in mental health-related ED visit characteristics by race and Hispanic ethnicity. Nationally representative estimates in this report are derived from data collected in the 2018–2020 National Hospital Ambulatory Medical Care Survey (NHAMCS). Rates of mental health-related ED visits by race and Hispanic ethnicity were highest among non-Hispanic Black adults (96.8 visits per 1,000 adults), followed by non-Hispanic White (53.4) and Hispanic (36.0) adults. Rates of ED visits for specific mental health disorders, including substance use disorders, anxiety disorders, and mood disorders, were also highest among non-Hispanic Black adults. A higher percentage of visits by Hispanic (57.7%) and non-Hispanic Black (49.5%) adults had Medicaid as the expected primary source of payment than visits by non-Hispanic White adults (36.1%).  

Skull Fractures In Female Versus Male Geriatric Patients Who Sustain Head Injuries

Head trauma is the leading cause of serious injury in the older adult population with skull fractures as a serious reported outcome. A study described in the March 2023 issue of The American Journal of Emergency Medicine that was conducted at two level-one trauma centers, serving a population of 360,000 geriatric residents aimed to evaluate the role of sex in the risk of skull fracture in patients over the age of 65. Among 5,402 patients enrolled, 3,010 (56%) were female and 2,392 (44%) were male. 4,612 (85%) of the head injuries sustained were due to falls, and 4,536 (90%) of all subjects were Caucasian. Overall, 199 patients (3.7%) sustained skull fractures. Males had a significantly greater rate of skull fracture when compared to females (4.6% vs 3.0%, OR 1.5, 95% CI: 1.2–2.1, p = 0.002). This trend also was seen across race/ethnicity and mechanism of injury. The outcome was unexpected, since previous literature indicated females being more susceptible to facial fracture.  

HEALTH TECHNOLOGY CORNER 

Inhalable Hydrogel Protects Lungs From SARS-Cov-2

Mutations in SARS-CoV-2, the virus that causes COVID-19, continue to produce new virus variants. Some mutations may confer resistance to the immunity induced by vaccines or prior SARS-CoV-2 infections. Thus, there is a need for strategies that could prevent infection by a range of SARS-CoV-2 variants. Physical barriers, such as the mucus lining of the airways, provide the first line of defense against infections. A research team at North Carolina State University set out to develop a way to reinforce this mucus barrier. They described their method, dubbed spherical hydrogel inhalation for enhanced lung defense, or SHIELD, in the journal Nature Materials on February 9, 2023. SHIELD consists of an inhalable powder of fine particles, less than 5 μm across, made from an absorbent polymer. The team tested whether it could protect against virus infection in mice. It was not toxic to cells in culture, and did not affect normal lung function in mice after two weeks of daily dosing.  

Technological Solutions To Loneliness—Are They Enough?

Loneliness is a major public health concern, particularly during pandemics such as COVID-19. It is extremely common and it poses a major risk to human health, such as higher rates of depression and increased mortality.Technological solutions including social media, robots, and virtual reality have been advocated and implemented to relieve loneliness. A paper in the March 2022 issue of the journal Bioethics explores the use of technological solutions from a normative perspective, asking whether and to what extent such measures should indeed be relied upon. A conclusion is that technological solutions are unquestionably part of the solution to loneliness, but that they cannot and should not constitute the whole solution because they arguably are insufficient to alleviate loneliness wholly and should not be perceived as sufficient. Another conclusion is that the essence of what it means to be human or the essence of human interactions cannot be substituted entirely by technological measures, sophisticated as they may be.

DEVELOPMENTS IN HIGHER EDUCATION

U.S. Senators Bernie Sanders (I-VT), chairperson of the Senate Health, Education, Labor, and Pensions (HELP) Committee, and Bill Cassidy (R-LA), ranking member of the Committee, on March 2, 2023 sent a letter to health care providers and other interested parties requesting information on the root causes of the current health care workforce shortage and potential ways to address it. The plan is to use what is derived from this invitational effort to identify bipartisan solutions that can be included in future legislation. Under new leadership in the 1st Session of the 118th Congress, the HELP Committee on February 16, 2023 conducted a hearing entitled, “Examining Health Care Workforce Shortages: Where Do We Go From Here?

Detailed workforce data can be derived for health professions, such as medicine, but that capability does not exist across the health professions. Although it is possible to generate information from professional organizations that collect membership data and political agencies that compile licensing data, uniformity often is lacking, which means that many gaps remain to be filled in constructing a comprehensive profile of health workforce shortages in the U.S.  Written responses to the letter from the two senators should be sent to HealthWorkforceComments@help.senate.gov by March 20, 2023. 

American College President Study

The American Council on Education’s (ACE’s) American College President Study (ACPS) has long served the higher education community as the most comprehensive, in-depth, and frequently cited source of information about the college presidency and pathways to higher education leadership. The last ACPS report was released in 2017. The recent survey of more than 1,000 presidents captures demographics; search and selection processes; career trajectories; and duties and responsibilities—with profiles of women presidents and presidents of color. New data this year will be revealed on the average age of aspiration, application, and appointment for college presidents by race, ethnicity, and gender, among other data points. Programming at the ACE annual meeting will include the unveiling of the report at a session called, “The American College President in 2023 and Beyond.”  

The Supreme Court And The Administration’s Student Debt Relief Plan

The fate of President Biden’s proposed student debt relief program is under review by the U.S. Supreme Court. An amicus brief signed by 128 House Republicans requests the Court to invalidate the program. Their argument is based on opposing an assertion of power to forgive every federal student loan in the country, potentially even a decade after the COVID-19 pandemic ends, which raises significant separation of powers concerns. House members contend that the power of the purse is one of Congress’s most potent checks against the executive branch, yet Petitioners’ overly broad reading of the HEROES Act risks encroaching on that power, as well as on Congress’s Article I legislative authority, by arrogating to the Secretary of Education the authority to forgive a trillion dollars in federal debt that otherwise would be owed to the Treasury. The brief states that the Court should require clear statutory authority before adopting an interpretation that risks significant conflict between the legislative and executive branches.  

Resources On Equal Athletic Opportunities Under Title IX

The Department of Education’s Office for Civil Rights on February 17, 2023 released three new resources to support equal opportunity in athletic programs consistent with Title IX of the Education Amendments of 1972. The documents are designed to help students, parents, coaches, athletic directors, and school officials evaluate whether a school is meeting its legal duty to provide equal athletic opportunity regardless of sex. The overview resource provides examples of the kinds of situations that could, depending upon facts and circumstances, raise Title IX concerns at any education level. The two specialized resources – one for K-12 schools and one for colleges and universities – offer information specific to these school communities. The resource for colleges and universities can be obtained here.

HEALTH REFORM DEVELOPMENTS

Since its enactment in 2010, the Affordable Care Act has undergone various refinements. A recent example stems from the passage of the Inflation Reduction Act (P.L. 117-169) that President Biden signed into law on August 16, 2022. One of its features is that Medicare will be able to negotiate drug prices starting in 2026. Nearly 20 years after the creation of the Medicare Part D program, the Centers for Medicare & Medicaid Services (CMS) will be able to negotiate drug prices directly with manufacturers. Thus far, the Congressional Budget Office (CBO) has estimated the total savings achieved each year for negotiation, but has not publicly identified the drugs anticipated to be negotiated. The March 2023 issue of the Journal of Managed Care+Specialty Pharmacy (JMCP) contains an article regarding drugs that are likely subject to Medicare negotiation.  

Medicare will be able to negotiate drug prices starting in 2026. By 2028, prices for 38 drugs dispensed in pharmacies and two drugs provided in physician offices will be negotiated. Medicare drug price negotiation will benefit patients with common diseases, such as diabetes, cancer, respiratory conditions, or cardiovascular disease. Combined, the 40 products eligible for negotiation in 2026-2028 accounted for $67.4 billion in gross Medicare spending in 2020. Part D drugs eligible for negotiation in 2026-2028 include seven inhalers, eight antidiabetics, five kinase inhibitors, and three oral anticoagulants. In all but five cases, high-spend drugs ineligible for negotiation were disqualified because of generic or biosimilar competition. By generating the list of drugs likely subject to Medicare negotiation in the initial years, the Journal article authors hope to provide researchers, policymakers, prescribers, and patient advocates with expectations on which drugs are expected to see reductions in beneficiary cost sharing. 

Consumer Adoption Of Digital Health

Based on a new survey released by Rock Health, a non-profit venture fund, and Stanford University’s Center for Digital Health, most U.S. adults prefer obtaining prescription refills and care for minor illnesses via telemedicine rather than in-person care. Since 2015, Rock Health annually has surveyed a U.S. Census-matched sample of adults to check the pulse on consumers’ attitudes toward and behaviors surrounding digital health. Respondents used their personal desktop, laptop, smartphone, or tablet to complete the survey in English. The 2022 study of more than 8,000 adults found that approximately two-thirds of Americans prefer in-person care for visits related to chronic conditions and mental health, while three-quarters of adults prefer in-person visits for annual wellness checks, emergency care, and physical therapy. 

In the 2022 Survey, 80% of all respondents reported having accessed care via telemedicine at some point in their lives, an increase of eight percentage points from 2021. While telemedicine use continues to vary across demographic segments, 2022 saw notable adoption increases among groups that have long been underserved in health care. The greatest year-over-year increases were observed among respondents aged 55+ (76%, up from 64%), respondents living in rural areas (73%, up from 60%), and respondents without health insurance at the time of the survey (50%, up from 37%). Telemedicine use also increased among women, with 82% of respondents reporting having used telemedicine (a 9% increase from 2021). Eighty-two percent of Hispanic respondents reported telemedicine use, reflecting a 9% increase since 2021, the greatest percentage point increase among all racial and ethnic groups captured by the Survey.

Protecting Beneficiaries From “Junk” Health Plan Coverage

A group of Senate Democrats sent a letter to Department of Health and Human Services Secretary  Xavier Becerra on February 22, 2022 urging the administration to take immediate action to address the availability of short-term, limited duration health insurance plans that violate the Affordable Care Act. The letter expresses concerns about individuals who will lose Medicaid coverage gained during the COVID-19 pandemic as state programs begin their redetermination processes. Beginning in April 2023, millions of Americans are at risk of losing Medicaid coverage that they have relied upon during the COVID-19 pandemic. Without additional protections they could find themselves enrolled in “junk” plans that do not provide comprehensive coverage or protection for individuals with pre-existing conditions. Steps also must be taken to ensure that these plans are not allowed to proliferate further.

AVOIDING THE THIRD RAIL

An old adage in the nation’s capital that many legislators have abided by is to avoid issues that are considered to be as perilous as being exposed to a subway third rail. The basic idea is that if you touch it, you will perish. Two prominent third rail items are the Social Security and Medicare programs. A vivid illustration occurred on Capitol Hill on February 7, 2023 during President Biden’s state of the union address when he suggested that Republicans may be inclined to damage those two programs, such as by reducing benefits or raising taxes.  

As stated at the opening of the Olympics every two and four years, “Let the games begin.” Democrats initiated their concerns by pointing to a proposal by Senator Rick Scott (R-FL) to sunset all federal programs every five years. If not renewed by fresh legislation then, they would be allowed to expire. Subsequently, he revised his plan by indicating that Social Security, Medicare, national security, veterans benefits, and other essential services would be specific exceptions.  

Whenever Democrats and Republicans are under assault, they have a gift for rapidly turning matters around so that any former accuser now becomes the accused. After vigorously denying that they would ever adopt behavior causing distress among Social Security and Medicare beneficiaries, Republicans retaliated by pointing to new rules from the Centers for Medicare and Medicaid Services (CMS) in the Biden administration aimed at reducing overpayments to Medicare Advantage plans. Approximately 40% of all beneficiaries are enrolled in Advantage plans that serve as an alternative to traditional Medicare by being administered by private health insurers. These plans now must pay back the government for overpayments as shown by a recently finalized rule that would over 10 years recoup more than $4 billion in overpayments to plans. Also, by offering to increase CMS support of Medicare Advantage by only 1% next year, the figure is looked upon as a benefit cut because it fails to keep pace with inflation.   

A steady growth in the number and proportion of individuals in the U.S. reaching age 65 every year guarantees that Congress must continue to devote attention to preserving the solvency of both the Social Security and Medicare programs. A related issue is the Medicaid program, which is funded by federal and state governments. It faces many of the same problems as Medicare, such as a growing number of older beneficiaries, many of whom must deal with multiple crippling health and health-related social problems involving long-term care. The COVID-19 public health emergency, which has been in effect since January 2020, is scheduled to end on May 11 of this year. A result is that states have had to begin a process of reassessing eligibility for their Medicaid-covered residents. Under the Families First Coronavirus Relief Act (FFCRA), states received enhanced federal funding in exchange for covering all enrolled Medicaid beneficiaries continuously. This requirement ends on April 1, after which states can begin disenrolling individuals who are determined to be eligible for Medicaid no longer.

ChatGPT AND A LITTLE TINK

Albert Einstein achieved fame for his development of theories of special and general relativity. He wrestled over the decades, however, with the task of producing a unified field theory that linked electricity, magnetism, gravity, and quantum mechanics. Whenever feeling stumped by obstacles in successfully completing that pursuit, he would state “I will a little tink.” English was not his native language.  

November 2022 marked the release of a new open source, natural language processing tool by OpenAI called ChatGPT. This new chatbot is designed to simulate human conversation in response to prompts or questions (GPT stands for “generative pretrained transformer”). In January 2023, Nature reported on two preprints and a pair of articles published in the science and health fields that included ChatGPT as a bylined author. These articles and their nonhuman “authors” already have been indexed in PubMed and Google Scholar.  

Two articles published in the March 2023 issue of the journal Lancet Digital Health discuss both the substantial ethical implications of this latest technology innovation as well as how it has potential to improve health care delivery. The publishing industry, for example, is at risk of undesirable consequences because when presented with a query, ChatGPT automatically will generate a response based on thousands of internet sources that may not involve any further interventions by the user. Scholarly manuscripts can be generated that also are accompanied by appropriate references. Ethical considerations abound concerning copyright, attribution, plagiarism, and authorship when AI produces academic text. These concerns especially are pertinent because when copy is AI generated, it currently is imperceptible to human readers and anti-plagiarism software. A significant concern is that the functionality of ChatGPT also has the capacity to cause harm by producing misleading or inaccurate content. 

Presently, ChatGPT is available to use without cost, but OpenAI's leadership has affirmed that free use is temporary and the product eventually will be monetized.  One commercial option for the platform could involve a form of paywall, which might entrench existing international inequalities in scholarly publishing. Although institutions in socioeconomically advantaged areas could probably afford access, those in low- and middle-income countries might not be able to do so, thereby widening existing disparities in knowledge dissemination and scholarly publishing.  

Apart from worrisome aspects of this new innovation, the delivery of health care services may benefit from expanded capabilities associated with further development of ChatGPT. One potential application could be to generate discharge summaries, which may be left under-prioritized that result in delays in patients’ discharges from clinical facilities or insufficient discharge summaries. All things considered, from a much wider perspective it would be advantageous to devote a little more “tink” to contemplating how to optimize the potential contributions this exciting technology has to offer its users.

CLIMATE CHANGE, INSECTS, AND HUMAN HEALTH

The science of astronomy for many centuries was influenced by a Ptolemaic formulation that placed the earth at the center of the universe, with other celestial bodies revolving around that planet. This conception subsequently was replaced by a Copernican model that viewed the sun as being at the center of the universe, with other bodies such as the earth revolving around it. In a parallel sense, it is possible to entertain a view that considers humans as being at the vital center of the animal kingdom, with all other creatures playing a more secondary role. The term anthropogenic has been coined to indicate the dominance of our species. The Oxford English Dictionary (OED) defines it as of or relating to (the study of) human origins or human development (in various contexts). It can be used as an adjective as shown by the expression “anthropogenic climate change.” As discussed in the February 2023 issue of the journal Ecological Monographs, climate warming is considered to be among the most serious of anthropogenic stresses to the environment, because it not only has direct effects on biodiversity, but it also exacerbates the harmful effects of other human-mediated threats.  

Among the most affected groups of animals are insects, central components of many ecosystems, for which climate change has pervasive effects from individuals to communities. The authors issue a warning that if no action is taken to better understand and reduce the action of climate change on insects, an ability to build a sustainable future based on healthy, functional ecosystems will be reduced drastically. A growing body of empirical literature shows that many populations of insects are declining rapidly across many parts of the biosphere. Observed trends in the demographics of many taxa, including important functional groups like pollinators, nutrient cyclers, and natural enemies, as well as in the abundance of crop, forest, and urban pests, currently is considered serious enough to merit profound concern. Important ecosystem services provided by insects are pollination, pest control, and nutrient recycling. Insects and their products also provide resources for higher trophic level organisms, including humans. In natural (unmanaged) ecosystems, abundances of pathogen and vector species are controlled through various food web interactions and habitat conditions, whereas anthropogenic land use changes, such as deforestation, habitat fragmentation, and agricultural development can modify these interactions with consequences for disease transmission affecting humans. The paper summarizes means of safeguarding insect populations for posterity and urges that initiatives be taken to implement them.