March 25, 2020

REPORTING OF RACE AND ETHNICITY IN THE MEDICAL LITERATURE

March 25, 2020

Far beyond mere academic interest, the collection of race and ethnicity data is an important way to identify and ultimately address disparities in access to treatment and inequalities in health care provision. The extent to which race and ethnicity, a multifaceted concept, is reported in the medical literature is extremely variable, according to an article published in the March 2020 issue of the Journal of Clinical Epidemiology. Investigators sought to determine objectively the quality of reporting of race and ethnicity in original medical research papers. A retrospective bibliometric analysis was used. Two independent investigators analyzed original articles investigating race and ethnicity, published between 2007 and 2018, in the 10 top-ranking academic journals in each of the following categories: general medicine, surgery, and oncology.

Among 995 original articles reporting race and ethnicity in the top 10 ranking medical academic journals, only 4.52% provided a formal definition of race and ethnicity and only 10.25% described the method used to classify individuals as to race and ethnicity. Eighty-one different race and ethnicity classifications were identified, but they often were imprecise and open to interpretation. A reasonable question is what, if anything, does this information add to what already is known? The adherence of leading medical academic journals to International Committee of Medical Journal Editors (ICMJE) and also the American Medical Association (AMA) Manual of Style guidelines was poor (still poor when considering previous studies). Pertinent questions are what is the implication and what should change now? The investigators conclude that there is significant room for improvement in the collection, reporting, and publishing of data describing ethnicity and race. Given that many national and international agencies, including the National Institutes of Health, require extensive data sets to identify and ultimately prevent health disparities, the lack of adequate reporting of race and ethnicity in the medical literature presents a significant and clinically relevant problem.

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TEETH, EARLY-LIFE ADVERSITY, AND MENTAL HEALTH RISK

Kristen Truong

March 25, 2020

Exposure to early-life adversity is one of the biggest risk factors for both mental and physical health problems across the lifespan. A need for objective measures that are noninvasive, inexpensive, and able to provide more accurate information about the presence and timing of childhood adversity has been recognized. If such a measure existed, its public health implications would be profound. For the first time, clinicians would be able with confidence to identify children on a population-wide scale who experienced childhood adversity during sensitive periods in development and therefore are at future risk for developing a psychiatric or other disorder. A manuscript appearing in the March 2020 issue of the journal Biological Psychiatry advances the proposition that teeth potentially could serve as a promising and actionable new tool capable of achieving key primary prevention goals. To support this claim, researchers first summarized empirical work from dentistry, anthropology, and archaeology on human tooth development and show how these fields collectively have studied human and animal teeth for decades, using teeth as time capsules that preserve a permanent, time-resolved record of life experiences in the physical environment.

Specifically, the investigators articulate how teeth have been examined in these fields as biological fossils in which the history of an individual’s early-life experiences is permanently imprinted, acknowledging that this line of research is related to, but distinct from, studies of oral health. They then integrate these insights with knowledge about the role of psychosocial adversity in shaping psychopathology risk to present a working conceptual model, which proposes that teeth may be an understudied yet suggestive new tool to identify individuals at risk for mental health problems following early-life psychosocial stress exposure. They end by presenting a research agenda and discussion of future directions for rigorously testing this possibility and with a call to action for interdisciplinary research to meet the urgent need for new biomarkers of adversity and psychiatric outcomes.

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AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

Kristen Truong

March 25, 2020

Characteristics And Health Status Of Informal Unpaid Caregivers: 2015-2017

The Centers for Disease Control and Prevention (CDC) has released a report, Characteristics and Health Status of Informal Unpaid Caregivers. In 2015, an estimated 17.7 million U.S. persons were informal caregivers who provided substantial services through in-home, unpaid assistance to their family members and friends. Caregiving can have many benefits, such as enhancing the bond between caregiver and recipient, but it also can place an emotional and physical strain on caregivers, leading to higher rates of depression, lower quality of life, and poorer overall health. Based on three years of Behavioral Risk Factors Surveillance System (BRFSS) data across 44 states, the findings indicate that approximately 20% of respondents were caregivers, and nearly 20% of these caregivers reported fair or poor health. Demographic characteristics and health status of unpaid caregivers, along with implications of the findings are discussed. Unpaid family and friend caregivers are paramount to the care of older adults, as well as the health system more generally. Unfortunately, caregivers are often under-supported and consequently may suffer adverse health effects. The report can be obtained here.

2020 Alzheimer’s Disease Facts And Figures

2020 Alzheimer’s Disease Facts and Figures is a statistical resource for U.S. data related to Alzheimer’s disease, the most common cause of dementia. This disease is the most common cause of dementia, accounting for an estimated 60% to 80% of cases. Recent large autopsy studies show that more than half of individuals with Alzheimer's dementia have Alzheimer's disease brain changes (pathology) as well as the brain changes of one or more other causes of dementia, such as cerebrovascular disease or Lewy body disease. This condition is called mixed pathologies, and if recognized during life is called mixed dementia. Difficulty remembering recent conversations, names or events is often an early clinical symptom. Apathy and depression also often are early symptoms. Later symptoms include impaired communication, disorientation, confusion, poor judgment, behavioral changes and, ultimately, difficulty speaking, swallowing, and walking. Background and context for interpretation of the data are contained in the Overview. Additional sections address prevalence; mortality and morbidity; caregiving; and use and costs of health care and services. A Special Report examines primary care physicians’ experiences, exposure, training, and attitudes in providing dementia care and steps that can be taken to ensure their future readiness for a growing number of Americans living with Alzheimer’s and other dementias. The report can be obtained here.

Critical Analysis Of Existing And Emerging Patient Safety Practices

Despite sustained national attention and notable successful interventions in recent years, patient safety remains a significant problem in the United States. Harms such as adverse drug events, healthcare-associated infections (HAIs), falls, and obstetric adverse events are responsible for thousands of deaths and hundreds of thousands of injuries each year. An estimate is that in 2017, there were 86 hospital-acquired conditions per 1,000 hospital discharges, a figure that has fallen steadily in recent years, but remains alarmingly high. The Making Healthcare Safer III report by the Agency for Healthcare Research and Quality (AHRQ) addresses this continuing problem by supporting the implementation of patient safety practices where appropriate, advancing a framework for patient safety transformation, and considering the contextual factors that can lead to successful use of patient safety interventions. Forty-seven practices are reviewed that target patient safety improvement in hospitals, primary care practices, long-term care facilities, and other healthcare settings. The practices are categorized among 17 chapters that represent harm areas including medication management and diagnostic errors. The practices include clinical decision support and those designed to prevent medication errors and reduce opioid misuse and overdose. The report can be obtained here.

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DEVELOPMENTS IN HIGHER EDUCATION

Kristen Truong

March 25, 2020

As the month of March 2020 draws to a close, the nation is experiencing an unprecedented array of governmental and non-governmental proactive and reactive initiatives to mitigate the impact of COVID-19. Closing K-12 to postgraduate education activities will exert a wide variety of strains on students and their families. For example, a health professional who also happens to be a single parent with children is placed in the unenviable position of trying to juggle the responsibility of going to work every day to provide care for patients while also contending with the challenge of assuming family life duties for offspring who are at home because of school closings.

Portions of the education sector are being affected in different ways. Classroom teachers throughout the nation have to figure out how best to furnish a comparable level of education for their students who now are at home rather than on school grounds. Children who depend on school nutrition programs for food need to have effective alternative ways of being fed satisfactorily. Colleges and universities fortunate enough to possess hefty endowments may not have any immediate concerns of having to make refund payments to students for dormitories that have been closed and classes that have been suspended indefinitely. The same is not true, however, for institutions with little in the way of financial reserves and that rely heavily on tuition income. A related concern is that the high cost of operating intercollegiate athletic programs for students cannot be offset by post-season tournament revenues derived from television and ticket sales.

Governmental Assistance For Education In Response To The Spread Of The Coronavirus

Phase 2 of a federal stimulus package in the form of the Families First Coronavirus Response Act (P.L. 116-127) expands paid family and medical leave for child care due to school and day care closings for both private and public employers with less than 500 employees. Recognizing that more assistance is needed, legislators continue to seek agreement on how to address related situations that include: (1) Continuation of school lunch programming; (2) Allow the secretary of education to defer student loan payments, principal, and interest for three months without penalty to the student, with an additional three months’ deferment available if necessary; (3) Ensure that students at eligible institutions whose semesters were ended due to the emergency do not have to return their Title IV aid or have the distributed aid count towards their loan limits; and (4) Allow institutions to issue work-study payments to a student who is unable to work due to work-place closures and grant institutions the ability to transfer unused work-study funds for supplemental grants.

Under a change announced on March 20, borrowers can suspend payments for two months by contacting their servicers and enrolling in “forbearance.” No interest would accrue during that time. The plan would apply to all loans made directly by the federal government and to a portion of those made by private lenders and guaranteed by the government under a program that ended in 2010. However, loans made under the federal guarantee program that are held by commercial institutions won’t qualify. Approximately 43 million Americans owe roughly $1.5 trillion in federal student loans. The typical family spends $179 a month on payments, according to a July 2019 report by the JPMorgan Chase Institute.

Accreditation In The Context of Disease Transmission Increases

The congressional legislative hopper contains bills aimed at improving accreditation. The necessity of focusing on initiatives that bear directly on controlling the spread of disease means that for the immediate future such legislation will not move forward. Examples are: H.R. 5768, the Accreditation Reform Act to amend the Higher Education Act of 1965 to protect students and taxpayers by modernizing evaluation and increasing transparency in the accreditation system, and for other purposes; and H.R. 5171 to authorize the National Advisory Committee on Institutional Quality and Integrity permanently. Currently, it must be reauthorized each time the Higher Education Act is extended or reauthorized. Meanwhile, Education Secretary Betsy DeVos announced finalization of a package of regulations on college accreditation that are designed to erase any distinction between regional and national accrediting agencies. If the original schedule is adhered to, they will be effective this coming July 1. Aimed at promoting innovation in higher education, consumer advocates have expressed concerns that new regulations will enable low-quality institutions to shop for friendly accreditors more easily, thereby allowing them to access federal funding.

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HEALTH REFORM DEVELOPMENTS

Kristen Truong

March 25, 2020

Across the decades, policymakers have strived assiduously to produce improvements pertaining to the metaphorical three-legged stool of health care quality, access, and cost. The Patient Protection and Affordable Care Act of 2010 came into effect in March of that year. It represented a highly comprehensive approach of dealing with a wide range of defects and deficiencies in health care that continued to persist in the first decade of the 21st century.

Until several weeks ago, efforts to reform health care have proceeded in incremental and uncoordinated ways. The sudden appearance of a new communicable disease in the form of a pandemic has resulted in an explosion of new initiatives launched through a combination of coordinated federal and state interventions. Such new efforts continue at a rapid pace, but they do so in a time of considerable uncertainty. Some essential issues that continue to call for a clear resolution involve the following considerations: the best way of slowing the spread of infection, accurately determining how many individuals continue to circulate freely as their infection goes undetected, understanding how long the current appearance of the disease will last, and even if it apparently disappears, what the likelihood is that it could resurface later in the year. Also, if an appropriate vaccine becomes available, it remains to be seen whether it will result in any untoward hazardous side effects.

Role Of The Health Workforce And Challenges It Faces

A steady accumulation of new cases of COVID-19 in both the U.S. and in other countries that occurs as diagnostic testing for the presence of this disease increases, means that much greater stress is being placed on the capacity of the network of health care services to deal with this situation. Apart from the basic question of whether there are sufficient numbers of many kinds of health professionals in appropriate venues, such as hospitals to meet patient demands for care, there is the matter of the increased risk of disease exposure these personnel must confront when providing treatment. Not all of these individuals have the protective equipment needed to prevent infection. Logistically, more effort is needed to increase the supply chain and ensure that effective masks and hazard protection clothing are distributed rapidly. Otherwise, a serious problem becomes even more threatening if front line health care practitioners are sidelined because they also become seriously ill.

The Left Hand Giveth While The Right Hand Taketh Away

Many actions taken with the best of intentions, unfortunately often are accompanied by unintended negative consequences. For example, according to the Congressional Research Service, the current COVID-19 outbreak may pose significant challenges for the United States’ blood supply. Mitigation strategies to prevent the spread of this disease, such as closures of schools and workplaces, have led to blood drive cancellations, resulting in a critical blood supply shortage in the Pacific Northwest (specifically, western Washington and Oregon). School closures, event cancellations, and other mitigation strategies in other areas of the country may provide challenges for maintaining a sufficient blood supply. The management and distribution of the supply in this nation is coordinated largely by private organizations (e.g., Red Cross), with some oversight by the Department of Health and Human Services (HHS). Congress may need to consider how best to address critical shortages, such as through HHS or the U.S. Food and Drug Administration’s (FDA) authority over blood safety and donation guidance.

The VA Health System Within A Nonexistent System

Calling U.S. health care a system is a misnomer. Rather than a single unified entity, it is a collection of various systems that include government providers (e.g., Veterans Health Administration and Medicare) and non-governmental providers (e.g., private sector employers and private insurance). At a time of COVID-19 crisis, the Veterans Administration is of special interest. Because of their age, patients who served in Vietnam, Korea, and World War II are an important part of a demographic group designated as being at high risk for this disease. The VA currently administers the provision of health care services for more than nine million beneficiaries. Having served their nation in time of need, every effort should be made to ensure that these individuals receive the kind of care they need in this period of crisis.

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RISING TO THE OCCASION

Kristen Truong

March 25, 2020

Ordinarily during a presidential election year, significant legislative proposals grind to a halt. The party controlling the White House would like to be able to enact laws that bolster its reputation in ways that strengthen the rationale for voters to retain it in office. Opponents in the other party are less inclined to aid in achievement of that goal. Instead, it is much more to their advantage to portray the incumbents as being ineffective and give the electorate good reasons for removing current officials from office.

A good crisis can act as a circuitbreaker that disrupts this pattern of doing business and it arrived in the form of a declaration by the World Health Organization that a pandemic is underway accompanied by the establishment of a national emergency by the Trump Admiistration regarding the outbreak of COVID-19. These developments have set in motion some extraordinary responses in the form of legislation aimed at providing nostrums for the perceived health and economic threats posed by this disease. The following description of the steps being taken may be considered partial as of the date this section of the newsletter is being written because each passing day stimulates the arrival of new responses to the challenges arising from the spread of communicable disease.

In phase one of providing financial assistance, the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (P.L. 116-123), which passed with near unanimous support in both the House and Senate, was signed into law by the President on March 6, 2020. The bill provides $8.3 billion in emergency funding for federal agencies to respond to the coronavirus outbreak. Of that amount, $6.7 billion is designated for the domestic response and $1.6 billion for the international response. The next major step taken was completion of the second supplemental legislative package aimed at seeking to contain and combat the COVID-19 pandemic. The president signed the Families First Coronavirus Response Act H.R. 6201 (P.L. 116-127) on March 18. The House had passed the bill on both a 363-40 vote on March 14 and a subsequent March 16 unanimous vote to add technical corrections. The Senate then passed the measure on a vote of 90-8 on March 18.

The scope of these initiatives is vast insofar as recognition is being accorded to major disruptions caused by health care facilities in the U.S. possibly being overwhelmed by the demand for services and economic dislocations that result from workers becoming unemployed, along with the production of essential goods and services being curtailed. The kinds of situations either addressed by existing initiatives or being contemplated for future action include: unemployment insurance; enhanced paid leave and sick leave; direct financial payments to individuals; federally guaranteed loans to employers; loans to distressed industries, such as airlines; and increased funding for medical supplies and equipment.

P.L. 116-127 makes it possible for group and individual health insurance plans to cover approved diagnostic tests as well as office visits, treatment at urgent care clinics, telehealth, and emergency room visits that result in orders for coronavirus diagnostic testing, insofar as the services received during the visit relate to testing or determining the need for testing. Plans will not be able to impose cost-sharing or subject enrollees to prior authorization or other medical management requirements.

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PRESIDENT’S CORNER

Kristen Truong

March 25, 2020

BY ASAHP PRESIDENT PHYLLIS KING

We are living in an unprecedented reality that is likely to have a transformational effect on aspects of our lives, especially higher education. No doubt everyone has had to demonstrate adaptability and creativity to address changes under challenging conditions. The pandemic has altered our routine lifestyles to one of disruption, social distancing and isolation. Use of technology has provided us with a means of continuity in operations and communications. This is a time to model resilience, persistence, strategic thinking, leadership and teamwork, as we all work together to recover.

The Higher Logic platform is a member benefit of ASAHP where you can share online your questions, concerns, announcements, best practices, and many other items (click here for the ASAHP Community). I encourage you to join this community and reach out to others sharing similar experiences. Show your support and learn from one another collectively how to handle challenging times and build a road to recovery. ASAHP is here for you.

The Association has been instrumental in providing resources for institutions of higher education. The following examples indicate efforts aimed at continuing to monitor COVID-19:

Interim Guidance for Administrators of US Institutions of Higher Education (IHE) to Plan, Prepare, and Respond to Coronavirus Disease 2019 (COVID-19)

Interim Guidance: Get Your Mass Gatherings or Large Community Events Ready for Coro- navirus Disease 2019 (COVID-19)

CDC Coronavirus Information

Harvard Medical School Coronavirus Resource Center

Department of Education Coronavirus Information and Resources for Schools and School Personnel

Federal Student Aid Guidance

Federal Student Aid FAQ

Inside Higher Ed Article - March 6, 2020

Inside Higher Ed Coronavirus Coverage

World Health Organization Coronavirus Information

White House Coronavirus Guidelines for America

Kaiser Family Foundation Tracking

HRSA Coronavirus Resources

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SOME REFLECTIONS ON A PANDEMIC

Kristen Truong

March 25, 2020

The early part of the 1600s was characterized by the plague in Europe. Vaccinations were unknown, so health authorities had to rely on other forms of conventional wisdom. Health officer Cristofano di Giulio of Prato in Italy wrote a manuscript back then with the title Libro della Sanità, in which he provided a summary of what he believed a public health officer ought to know in time of plague.

He asserted that it has been proven by experience that to respond to an epidemic, first of all it is necessary to resort to the majesty of God and in the intercession of the Holy Virgin and of the Saints. Then it is necessary to observe with every possible diligence the following rules: (1) disinfect with sulphur and perfumes all homes or rooms wherein there has been death or sickness; (2) separate at once the sick from the healthy as soon as the case of illness is discovered; (3) burn and take away at once those objects such as have been used by the deceased or by the sick; and (4) shut up straight away all houses wherein there have been infected patients and keep them closed for at least 22 days so that those who are segregated inside the houses will not carry the infection to other individuals.

Physicians suggested that patients should be treated at a distance with the barber-surgeon of the lazaretto (i.e., a pest house for isolating persons believed to have the disease or to be incubating it), shouting from the window the quality, sex, condition of the patient, and the stage of illness. A cautious physician then would shout back the cure from a safe distance. Another belief was that even though a patient had recovered, convalescents remained infectious for some time.

Unfortunately, related public health measures failed to produce salutary outcomes. Orders for the mass slaughter of dogs and cats, in the belief that the coats of these animals harbored the plague bearing miasma, made life easier for rats, the creatures eventually discovered to be more closely associated with disease outbreaks. Oddly enough, resorting to the majesty of God often led to crowded religious processions and packed houses of worship, which aided in the rapid transmission of infection.

1960 Nobel Prize winner Sir Macfarlane Burnet stated in 1962 that “One can think of the middle of the 20th century as the end of one of the most important social revolutions in history, the virtual elimination of the era of infectious diseases as a significant factor in social life.” Since then, the appearance of Zika, Ebola, SARS, MERS, and other devastating communicable diseases has shown that his prediction was issued prematurely. Enormous progress over the past four centuries has been made in medical laboratory procedures, hospital care, health devices, communication capabilities, and the highly sophisticated education and training of health professionals. These developments will have a decisive bearing on how successful efforts will be in eliminating the COVID-19 threat.

For the present, however, it is reasonably safe to assume that household pets are in no immediate danger of being slaughtered and physicians will not find it necessary to stand across the street from homes and holler instructions through bullhorns to their beleaguered patients.

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QUANTIFYING HEALTH SYSTEMS’ INVESTMENTS IN SOCIAL DETERMINANTS OF HEALTH

John Colbert

February 25, 2020

Trends Archives

Social determinants (e.g., conditions in which individuals are born, grow, work, live, and age) are seen as accounting for substantially more of the variation in health outcomes than medical care does while interest in addressing these determinants has increased markedly in recent years. According to a study reported in the February 2020 issue of the journal Health Affairs, the past decade has involved a growing recognition of the importance of social determinants of health for health outcomes. Meanwhile, the degree to which health systems in the U.S. are investing directly in community programs to address social determinants of health as opposed to screening and referral is uncertain.

Researchers conducting this investigation searched for all public announcements of new programs involving direct financial investments in social determinants of health by U.S. health systems from January 1, 2017, to November 30, 2019. They identified 78 unique programs involving 57 health systems that collectively included 917 hospitals. The programs involved at least $2.5 billion of health system funds, of which $1.6 billion in 52 programs was committed specifically to housing-focused interventions. Additional focus areas were employment (28 programs, $1.1 billion), education (14 programs, $476.4 million), food security (25 programs, $294.2 million), social and community context (13 programs, $253.1 million), and transportation (six programs, $32 million). These figures demonstrate that health systems are making sizable investments in social determinants of health. To cite one example, housing-related programs included strategies, such as direct building of affordable housing, often with a fraction set aside for homeless patients or those with high use of health care; funding for health system employees to purchase local homes to revitalize neighborhoods; and eviction prevention and housing stabilization programs.

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THE ROAD TO IMMORTALITY IS PAVED WITH EPONYMS

John Colbert

February 25, 2020

Trends Archives

The health sphere represents fertile ground for the production of eponyms. Prominent examples are Salk vaccine, Alzheimer’s disease, Parkinson’s disease, and Obamacare. Perpetual glory appears to be associated with having one’s name used in such ways and the website Whonamedit.com provides thousands of examples of medical eponyms. Is the practice of employing them a constructive use of nomenclature or has it become more timeworn than beneficial? This kind of question is addressed in a manuscript that appeared in the February 11, 2020 issue of the journal Neurology in which a study is described that assesses historical trends of medical eponym use in neurology literature, and knowledge and attitudes among current trainees related to eponyms. The yearly prevalence of eponyms among neurologist-authored publications ranged from 15% and 25%, with a mean of 21%. The total number of unique eponyms appearing in titles and abstracts increased from 693 in 1988 to 1,076 in 2013, representing 1.8% average annual growth.

Worth noting is that medical eponyms represent a polarizing issue among clinicians, including neurologists. Impassioned calls for the abandonment of eponyms in the published literature and in clinical use have appeared regularly in the literature for decades. Supporters explain that eponyms are concise and memorable, providing an effective shorthand to communicate precisely in clinical settings. Eponyms also may represent an essential thread of medical history, an oral tradition transmitted to successive generations of students through teaching rounds. An opposing perspective is that eponyms can be viewed as lacking accuracy and being characterized by inconsistent usage, frequent misattribution of credit, and occasional recognition of individuals with unethical research practices, such as Nazi-affiliated physicians. Study findings indicate that residents with at least one year of neurology training reported familiarity with significantly more eponyms than those before neurology training (p < 0.001). For familiar eponyms, most residents either were unaware of an alternative descriptor or preferred using the eponym. Despite recognizing both the benefits and drawbacks of eponyms, the vast majority of trainees stated that historical precedent, pervasiveness, and ease of use would drive the continued use of eponyms in neurology. For the nonce, it seems reasonable to predict that this path to immortality will remain open.

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

John Colbert

February 25, 2020

Trends Archives

2020 Patient Data Breach Barometer

In 2019, the healthcare industry continued to be plagued by data breaches involving sensitive patient information, with public reports of hacking jumping a staggering 48.6% from 2018. This number of reported hacking incidents is a reminder of how vulnerable patient data remain. An analysis by Protenus is based on 572 health data breaches reported to the U.S. Department of Health and Human Services (HHS), the media, or some other source during 2019. For the 481 incidents where data exist, breaches had an impact on 41,404,022 patients, which is likely to be a huge underestimate. Two incidents for which there were no data affected 500 dental practices and clinics and could affect significant volumes of patient records. The number of breaches went from 503 in 2018 to 572 in 2019, along with a substantial increase in the number of affected records. In 2019, the total number of affected records almost tripled when compared to 2018 data (i.e., 15,085,302 affected records).

Self-reported Marijuana Use In Electronic Cigarettes Among U.S. Youth

The National Youth Tobacco Survey (NYTS) is a cross-sectional, school-based study conducted annually using a stratified, three-stage cluster sampling design to produce a nationally representative sample of middle school (grades 6-8) and high school (grades 9-12) students in the U.S. They were asked about whether they ever have used marijuana in an e-cigarette. As reported in the February 4, 2020 issue of the Journal of the American Medical Association, the study identified a significant increase in self-reported ever marijuana use in e-cigarettes from 2017 to 2018 among U.S. students. Prevalence estimates reported for all students (14.7%) and current e-cigarette users (53.5%) in 2018 also were much higher than those reported in 2016 (8.9% and 39.5%, respectively). The increase in marijuana use in e-cigarettes could be attributable to the increase of sales of pod-mod–style e-cigarette products, access to marijuana through informal sources (e.g., friends, family members, illicit dealers), and reduced perception among adolescents of the harms of marijuana use.

HEALTH TECHNOLOGY CORNER

Light-Adapted Electroretinogram Differences In Autism Spectrum Disorder

A new eye scan could help identify autism in children years earlier than currently possible. This non-invasive device uses a hand-held instrument to locate a pattern of subtle electrical signals in the retina that are different in children on the autism spectrum. According to a manuscript published on February 7, 2020 in the Journal of Autism and Developmental Disorders, the retina is an accessible model of neural connectivity in the brain where specific retinal signaling pathways can be probed and measured with an electroretinogram (ERG). Light-adapted (LA) electroretinograms (ERGs) of individuals with autism spectrum disorder (ASD) were compared to control subjects in a multicenter study of children. The results show that the LA-ERG is a potential marker for neurodevelopmental conditions, such as ASD in children. These potential biomarkers for ASD also could allow for early detection of other disorders, such as attention deficit hyperactivity disorder (ADHD).

Evolving Magnetically Levitated Plasma Proteins Detect Opioid Use Disorder As A Model Disease

As reported on January 29, 2020 in the journal Advanced Healthcare Materials, new research from the University of British Columbia, Harvard Medical School, and Michigan State University suggests that levitating human plasma may lead to faster, more reliable, portable, and simpler disease detection. The researchers used a stream of electricity that acted like a magnet and separated protein from blood plasma, which is the clear, liquid portion that remains after red blood cells, white blood cells, platelets, and other cellular components are removed. The basic notion is that as plasma proteins are different densities, when separated the proteins levitate at different heights, and therefore become identifiable. An evaluation of these types of proteins and how they group together can produce a picture that identifies whether a patient has the possibility of contracting a disease or becoming addicted to drugs, such as opioids.

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HEALTH REFORM DEVELOPMENTS

John Colbert

February 25, 2020

Trends Archives

Debates by candidates seeking to be the Democratic party’s nominee to run against President Donald Trump in the upcoming election indicate that health care is a major policy issue that cries out for significant improvement. Proposals range from eliminating private forms of insurance coverage available through employers to protection offered solely by the federal government to a single-payer government operated program that also includes options for other forms of coverage. The latter choice recognizes that some beneficiaries may prefer having insurance provided by an employer rather than being compelled to participate in a governmental program.

Recent findings from the National Health Interview Survey help to highlight why some form of remediation is considered desirable. An estimated 14.2% of U.S. residents said they or a family member had problems paying medical bills in 2018, down from 19.7% in 2011, according to a report issued in February 2020 from the Centers for Disease Control and Prevention. The percentage of individuals in families having problems paying medical bills was higher among females (14.7%), children (16.2%), and non-Hispanic black persons (20.6%) compared with males, adults, and other racial and ethnic groups, respectively. Among persons under age 65, those who were uninsured were more likely than those with Medicaid or private coverage to have problems paying medical bills.

The Challenge Of Financing The Costs Of Health Care

National spending on healthcare is projected to grow 5.5% between 2018 and 2027, according to the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary's annual report that was issued in February last year. This growth would outpace average projected GDP growth by 0.8%. The forecast means the healthcare segment of the U.S. economy would climb to 19.4% by 2027, up from 17.9% in just two years. Medicare for All is one proposal being touted as a way of addressing the challenge of financing the cost of health care. Differences exist among advocates of this approach regarding whether it will be necessary to impose additional taxes. Individuals in favor of higher taxation believe that the amount beneficiaries must pay will be offset by eliminating other expenses associated with deductibles, co-payments and co-insurance.

A concern is that even if Medicare for All ever becomes the law of the land, there is no guarantee that it will be implemented and sustained as originally planned. The Affordable Care Act furnishes compelling evidence of the kinds of unintended alterations that can occur once a significantly large national endeavor leaves the launching pad. An original element of the ACA pertained to Community Living Services and Supports (CLASS) as a means of meeting the costs of long-term care. Seventeen months after the law was enacted, however, the HHS Secretary announced that CLASS would be abandoned because it was unsound financially. Reforming the federal tax code in 2017 resulted in repeal of the individual mandate to purchase health insurance or pay a penalty for failing to do so. In December 2019, legislation was enacted to eliminate three mechanisms designed to pay for the ACA: the so-called “Cadillac Tax”, the “Health Insurer Tax”, and the “Medical Device Tax.”

Curbing Waste In The Provision Of Health Care Services

A review of 54 unique peer-reviewed publications, government-based reports, and reports from the gray literature described in the October 15, 2019 issue of the Journal of the American Medical Association yielded the following estimated ranges of total annual cost of waste: (1) failure of care delivery, $102.4 billion to $165.7 billion, (2) pricing failure, $230.7 billion to $240.5 billion, (3) fraud and abuse, $58.5 billion to $83.9 billion, and (4) administrative complexity, $265.6 billion. The estimated annual savings from measures to eliminate waste were as follows: (1) failure of care delivery, $44.4 billion to $97.3 billion, (2) pricing failure, $81.4 billion to $91.2 billion, and (3) fraud and abuse, $22.8 billion to $30.8 billion. No studies were identified that focused on interventions targeting administrative complexity. The estimated total annual costs of waste, including items not listed here, were $760 billion to $935 billion and savings from interventions that address waste were $191 billion to $286 billion.

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PULLING BACK THE CURTAIN

John Colbert

February 25, 2020

Trends Archives

Two events that are prominent in the nation’s annual political pageant enable voters to obtain a glimpse of the kinds of policies that may be concealed behind the curtain. One is the President’s State of the Union Address, which makes it possible to boast of past achievements and describe in broad terms anticipated future legislative initiatives. While members of the President’s party cheer vigorously at each utterance, Congressional members of the opposition party typically are more reticent. The second noteworthy event is the release by the Administration of its federal budget for the next fiscal year. Stock full of details on how money should be allocated, it’s relatively easy to determine which budgetary elements are destined to undergo some exceptionally rough legislative sledding based on who cheered wildly at the State of the Union address and who remained silent.

Lobbyists and leaders of special interest groups pay close attention to the proposed federal budget. Each year, the plot lines in the drama are reasonably clear. Many liberals tend to fret that important discretionary social programs involving health care and education will be seriously underfunded, while proclaiming that some military programs are too bloated and either should be eliminated outright or undergo significant reductions in spending. Many conservatives view matters differently and it is rare for them to fail to acknowledge what they perceive as redundant and wasteful amounts of money allocated for ineffective social programs.

The budget sent to Congress on February 10, 2020 contained some of the following items:

The administration proposes funding $38.7 billion for the National Institutes of Health (NIH) in FY 2021, which amounts to $3 billion less money or more than a 7% cut below the FY 2020 enacted program level.
The Agency for Healthcare Research and Quality (AHRQ) would be funded as a new institute within the NIH in the amount of $257 million, representing an $82 million (24%) reduction below AHRQ’s current funding level.
On the plus side, the budget proposes a nearly $900 million increase in career and technical education funding.
The Food and Drug Administration (FDA) would obtain a small budget increase in FY 2021 ($25 million, for a total of $3.29 billion).

Apart from legislation that involves spending, bipartisan cooperation has aided in producing efforts aimed at protecting patients from surprise medical billing. House Ways and Means Committee Chairman Richard Neal (D-MA) and Ranking Member Kevin Brady (R-TX) on February 7, 2020 announced the Consumer Protections Against Surprise Medical Bills Act of 2020 while Education and Labor Committee Chairman Robert “Bobby” Scott (D-VA) and Ranking Member Virginia Foxx (R-NC) revealed their surprise billing legislation, the Ban Surprise Billing Act.

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GEOGRAPHIC INFLUENCE ON HEALTH DISPARITIES

John Colbert

February 25, 2020

Trends Archives

Individuals possess distinguishing characteristics, such as age, education, level of income, extent of health insurance coverage, and degree of health literacy that contribute to the likelihood they will experience health disparities. Where they live and work also will play an important role due to a rural-urban divide that exists. For example, an article in the January 2020 issue of the American Journal of Preventive Medicine discusses how in the U.S., rural residents have poorer health than urban residents and this disadvantage is growing. Compared with metropolitan county residents, inhabitants of the most rural counties were seven percentage points more likely to have a usual source of care (81% vs 74%), but their providers were 13 percentage points less likely to be physicians (22% vs 35%). Despite having to travel longer to reach their usual source of care providers, residents of the most rural counties were 12 percentage points less likely than metropolitan residents to have usual source of care providers with office hours on nights and weekends (27% vs 39%).

Rural counties make up approximately 80% of the land area of this nation, but they contain less than 20% of the U.S. population. The relative sparseness of the population in rural areas is one of many factors that influence the health and well- being of the inhabitants of these places. An important difference pertaining to the health workforce is that some rural counties may lack the presence of a single member of a particular health profession, such as dentistry or psychiatry. Older patients with chronic ailments often require rehabilitation care, which typically requires a team consisting at a minimum of physicians, nurses, dietitians, occupational therapists, physical therapists, and speech therapists.

Hospitals often serve as the main type of venue where such teams are located, but as Seema Verma, Administrator of the Centers for Medicare & Medicaid Services, pointed out in a presentation she made on February 12, 2020 at the National Rural Health Association’s policy institute, more than 120 rural hospitals have closed since 2010, which does not appear to be a step in the right direction of ensuring the presence of a sufficient network of health providers. Unlike students who live in big cities that have access to several academic institutions with health professions programs reachable by subway and bus, rural students lack this luxury and may live hundreds of miles from educational resources. Fortunately, telehealth services can benefit patients and online degree programs may be available to enable the pursuit of academic degrees necessary to become health professionals, but it is not the same as having face-to-face kinds of opportunities that exist in urban areas.

Health policy is in a state of flux. Some presidential candidates propose new approaches, such as Medicare for All, but it is not entirely clear what impacts possibly could materialize that affect the delivery of health care services. Changes in reimbursement patterns, for example, either could slow the pace of hospital closings in rural areas or accelerate their disappearance if financing levels prove to be less than what is necessary to enable these facilities to remain afloat financially.

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GEOGRAPHY DETERMINES WHEN A DEATH CAN BE DECLARED

John Colbert

January 24, 2020

Trends Archives

Apart from decision fatigue, there is the issue of decision confusion. An example is that it is possible for an individual to be pronounced dead in one state, but not dead in a neighboring jurisdiction. As described in an article appearing on December 24, 2019 in the Annals of Internal Medicine, this situation exists because only 36 states have incorporated the complete language of the Uniform Determination of Death Act (UDDA) into their respective definitions of death. An original goal was for all states to adopt the UDDA as the legal standard for death by neurologic criteria (DNC). Instead, there is ongoing confusion about DNC since medical standards of determination vary, public acceptance is inconsistent, and responses to family objections have ranged from continuation of organ support indefinitely to unilateral discontinuation. Unresolved problems pertain to: (1) lack of uniformity in the medical standards used to determine DNC, (2) uncertainty about whether “all functions of the entire brain, including the brainstem” entail hormonal functions, (3) the UDDA does not address whether consent is needed before a determination of DNC, and (4) the UDDA does not address religious objections to discontinuation of organ support after DNC.

In a related vein, a debate is underway in the field of Alzheimer’s disease (AD) research over the definition of the disease itself. As described in the December 11, 2019 issue of the journal Science Translational Medicine, a problem is that the terms dementia and AD have become interchangeable. Arguments in favor of using a biological versus a clinical diagnosis for AD are that: the latter is not specific for any etiology; a biological definition of AD will lead to a better understanding of the sequence of events that leads to cognitive impairment and dementia; biological markers will improve efficiency of clinical trials; and a biological definition of AD enables study of the disease from the preclinical stage through all symptomatic stages and of all disease phenotypes, not only the memory loss phenotype.

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A CONCEPTUAL ANALYSIS OF DECISION FATIGUE

John Colbert

January 24, 2020

Trends Archives

The Lovesong of J. Alfred Prufrock by T.S. Eliot contains the following verse:

Time for you and time for me,
And time yet for a hundred indecisions,
And for a hundred visions and revisions,
Before the taking of a toast and tea.

The memory of the TRENDS newsletter’s editor of this portion of the poem was triggered while perusing an article on the topic of decision fatigue that appeared in the January 2020 issue of the Journal of Health Psychology, in which it is estimated that an American adult makes 35,000 decisions each day. While some of them seemingly are benign, an emerging body of science indicates that making decisions may possess negative ramifications for controlling one’s behavior and the quality of subsequent decisions. The phenomenon is known as “decision fatigue,” an impaired ability to make decisions and control behavior as a consequence of repeated acts of decision-making that often lead to choices that seem impulsive or irrational. Decision-making is a central component of modern health care, with each decision possessing some level of influence on patient outcomes. With a substantial proportion of all adults possessing at least one chronic condition, decision-making may be considered a central facet of day-to-day chronic disease self-management.

Decision fatigue as a concept has been applied scantily to health care disciplines, despite its potential relevance to inform the decision-making behaviors of patients and clinicians. If health professionals are working to the point where they are in severe states of ego depletion (manifesting as decision fatigue) and are not in an ideal cognitive state to make logical and safe decisions for patients, an exploration of decision fatigue may serve as a highly relevant and necessary endeavor. Hence, decision fatigue analysis may possess significance to inform regulatory policies related to health care employee workload.

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AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

John Colbert

January 24, 2020

Trends Archives

U.S. Investments In Medical And Health Research And Development 2013 - 2018

A new report from the advocacy group Research!America finds that the total spending on health and medical research was more than $194 billion in 2018. Since 2013, medical and health R&D spending has increased by $51 billion. Industry and academia funding have increased by nearly 40% over this time. Industry was responsible for two-thirds of the 2018 R&D funding, while federal agencies invested about 22%. Academic institutions and foundations made up the rest. Spending on health care far outweighs spending on health research. In 2018, $3.6 trillion was spent on care, which means research funding accounts for only five cents of every health sector dollar. The report can be obtained here.

More Americans Delaying Medical Treatment Due To Cost

Approximately one out of four Americans say the cost of treatment caused them to delay care for a serious medical condition, according to Gallup’s annual Health and Healthcare poll in 2019. An additional 8% of respondents indicated that costs played a factor in deciding to delay seeking care for less serious conditions. In 2018, 19% of Americans claimed that treatment costs led to a delay in treatment for a serious condition. The poll tracked a few trends within this data, including the following: On the basis of household income, 36% percent of adults with household income of less than $40,000 reported delaying treatment for a serious condition, a jump in 13 percentage points since last year. Rates stayed relatively flat for middle-and high-income households. Americans who reported having a pre-existing condition, or living with someone who has, were more likely to delay medical care for a serious condition this year compared to 2018. According to Gallup, these trends could have broad implications for both the health care system and the economy. The report can be obtained here.

Do Advanced Driver Assistance And Semi-Automated Vehicle Systems Lead To Improper Driving Behavior?

According to a report from the AAA Foundation for Traffic Safety, the ultimate goal of advanced driver assistance systems (ADAS) is to increase traffic safety and driving comfort. Despite their potential safety benefits, there are concerns about unintended consequences associated with intermediate levels of automation. In these scenarios, speed control and/or steering are automated, but the driver still is required to monitor traffic and be ready to resume control. A key concern is that drivers may become inattentive due to engagement in non-driving-related tasks or become drowsy while driving using these systems. As drivers gain experience using advanced driver assistance systems (ADAS), such as adaptive cruise control and lane-keeping assist, they also are more likely to drive distracted while using the systems, according to research from AAA Foundation for Traffic Safety. Conducted in collaboration with the Virginia Tech Transportation Institute, the study found that drivers with experience using ADAS were nearly twice as likely to engage in distracted driving while using the systems compared to when they were driving without the systems. Researchers noted the opposite effect in drivers with less familiarity using the technology. Those drivers were less likely to drive distracted with the systems engaged compared to when the systems were not in use. The report can be obtained here.

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

John Colbert

January 24, 2020

Trends Archives

Adult Physical Inactivity Prevalence Maps By Race/Ethnicity

According to new state maps of adult physical inactivity made available by the Centers for Disease Control and Prevention (CDC) in January 2020, all states and territories had more than 15% of adults who were physically inactive and the estimate ranged from 17.3 to 47.7%. Inactivity levels vary among adults by race/ethnicity and location. The data come from the Behavioral Risk Factor Surveillance System (BRFSS), an ongoing state-based, telephone interview survey conducted by CDC and state health departments. Maps use combined data from 2015 through 2018 and show noticeable differences in the prevalence of physical inactivity by race/ethnicity. Hispanics (31.7%) had the highest prevalence of physical inactivity, followed by non-Hispanic blacks (30.3%) and non-Hispanic whites (23.4%). Non-Hispanic blacks and Hispanics had a significantly higher prevalence of inactivity than non-Hispanic whites in the majority of states.

Driving Under The Influence Of Marijuana And Illicit Drugs Among Persons Aged ≥16 Years—U.S.

Data from the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health (NSDUH) indicate that in the United States during 2014, 12.4% of all persons aged 16–25 years reported driving under the influence of alcohol, and 3.2% reported driving under the influence of marijuana. This report provides the most recent national estimates of self-reported driving under the influence of marijuana and illicit drugs among persons aged ≥16 years, using 2018 public-use data from NSDUH. Prevalences of driving under the influence of marijuana and illicit drugs other than marijuana were assessed for persons aged ≥16 years by age group, sex, and race/ethnicity. During 2018, 12 million (4.7%) U.S. residents reported driving under the influence of marijuana in the past 12 months; and 2.3 million (0.9%) reported driving under the influence of illicit drugs other than marijuana. Driving under the influence was more prevalent among males and among individuals aged 16–34 years.

HEALTH TECHNOLOGY CORNER

Benefit To Patients Using Wearable Devices Such As Fitbit Or Health Apps On Mobiles

According to a study reported in the December 2019 issue of the American Journal of Medicine, wearable devices have become a standard health care intervention with emerging health care technologies. These devices are designed to promote healthy behaviors and decrease risk for chronic ailments, such as cardiovascular disease and diabetes. A systematic search of 550 articles revealed little indication that wearable devices provide a benefit for health outcomes. Only one study showed a significant reduction for weight loss among participants. No significant reduction was discovered in cholesterol or blood pressure. A conclusion reached is that current literature evaluating wearable devices indicates little benefit of these items on chronic disease health outcomes. Although wearable devices play a role as a facilitator in motivating and accelerating physical activity, current data do not suggest other consistent health benefits.

Light-Degradable Hydrogels As Dynamic Triggers For Gastrointestinal Applications

Different kinds of medical devices can be inserted into the gastrointestinal tract to treat, diagnose, or monitor GI disorders. Many of these items need to be removed by endoscopic surgery after their function has been performed. According to an article published on January 17, 2020 in the journal Science Advances, engineers at the Massachusetts Institute of Technology have developed a way to trigger such devices to break down inside the body when they are exposed to light from an ingestible light-emitting diode (LED). A potential advantage is that light can act at a distance and doesn't need to come into direct contact with the material being broken down. Also, light normally does not penetrate the GI tract, so there is no chance of accidental triggering. Light-triggerable hydrogels have the potential to be applied broadly throughout the GI tract and other anatomic areas. By demonstrating the first use of light-degradable hydrogels in vivo, biomedical engineers and clinicians are provided with a previously unavailable, safe, dynamically deliverable, and precise tool to design dynamically actuated implantable devices.

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DEVELOPMENTS IN HIGHER EDUCATION

John Colbert

January 24, 2020

Trends Archives

Supplementing the information provided on page three of this issue of the newsletter, it is worth noting that the appropriations portion of the bill for higher education programs provides $2.5 billion, an increase of $163 million above the 2019 enacted level and $941 million above the President’s budget request. For federal student aid programs, the bill provides $24.5 billion, which is $75 million above the 2019 enacted level and $1.5 billion above the President’s budget request. Within this amount, the bill furnishes $865 million for the Supplemental Educational Opportunity Grant (SEOG) program, $1.2 billion for Federal Work Study, and an increase to the maximum Pell grant to $6,345.

A report issued on December 10, 2019 by the Pew Charitable Trusts on how the U.S. has changed in key ways in the past decade indicates that nonwhites now account for the majority of the nation’s newborns, as well as the majority of K-12 students in public schools. More than half of newborn babies in the U.S. are racial or ethnic minorities, a threshold first crossed in 2013. Nonwhite students also account for the majority of the nation’s K-12 public school students. As of fall 2018, children from racial and ethnic minority groups were projected to make up 52.9% of public K-12 students. With the passage of time, these facts will have an enormous impact on higher education in general and on the health professions in particular. Future issues of the ASAHP newsletter TRENDS will serve as a vehicle for discussing how the education sector will be affected by these kinds of societal changes.

Costs Associated With Attending College

Year-over-year increases in college expenses have grown steadily in the U.S. since 1981. Although the Pell Grant Program also has expanded at regular intervals, the maximum does not align well with much higher tuition costs. Consequently, students and their families increasingly find it necessary to take out various kinds of loans. Beyond the day when degrees are awarded, the amount of debt borne by recent college graduates may delay the attainment of milestones associated with adulthood later in life, such as buying a house, getting married, and having children. The situation is even more gloomy for students who have incurred substantial debt, but never ended up graduating from college.

A report made available on December 31, 2019 from the National Center for Education Statistics (NCES) describes four measures of the price of undergraduate education in the 2015–16 academic year: total price of attendance (tuition and living expenses), net price of attendance after all grants, out-of-pocket net price after all financial aid, and out-of-pocket net price after all aid excluding student loans. Estimates are based on the 2015–16 National Postsecondary Student Aid Study, a nationally representative survey of students enrolled in postsecondary institutions in the 50 states, the District of Columbia, and Puerto Rico. The total price of attendance consists of tuition and nontuition expenses (fees, books, supplies, transportation, and living expenses )., For example, full-time students at public two-year institutions had the lowest average total price of attendance at $16,100 in 2015-16. The average total price of attendance was higher at public four-year institutions ($26,900), higher still at for-profit institutions ($32,600), and highest at private non-profit four-year institutions ($48,000). The percentage of students with loans was greatest at private for- profit schools (74%) and lowest at public 2-year institutions (20%).

Opposition To Student Loan Forgiveness Rule

Congressional Democrats aim to prevent implementation of a Department of Education policy that would make it more difficult for federal student loan borrowers to cancel their debt based on misconduct by any college. Set to take effect on July 1 of this year, the Trump administration policy that was finalized last year establishes more stringent rules for when the government will wipe out the debt of students claiming they were misled or deceived by a higher education institution. Democrats are using the Congressional Review Act, a tool that allows Congress to stop recently enacted regulations with a simple majority in both chambers and the president's signature.

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HEALTH REFORM DEVELOPMENTS

John Colbert

January 24, 2020

Trends Archives

Approximately 18% of the U.S. economy, the largest in the world, is represented by the health sector, which suggests that there always will be something occurring within that domain that will prove to be newsworthy. Typical stories in the media and relevant topics in policy discussions revolve around the central issues of cost, quality, and access. The last item is guaranteed to continue to attract significant attention as long as there are any individuals in this country who lack health insurance coverage.

The Patient Protection and Affordable Care Act was signed into law by President Barack Obama on March 23, 2010. Usually referred to as either the ACA or Obamacare, this key piece of legislation has been in the news since its various provisions began to unfold. Its enactment was supported wholly in Congress by Democrats in both legislative chambers, without a single Republican vote. That outcome alone essentially assured that the years ahead would be marked by strenuous efforts to repeal and replace its most important features either in whole or in part. Republicans came close to repealing the ACA in 2017 when they were the majority in both the House and the Senate and President Donald Trump occupied the White House, but the attempt did not meet with success, albeit by a close margin. Failure in Congress did not mean that opposition fervor would be diminished, however, as repeal efforts then shifted to the judicial arena.

Repeal Of the Individual Mandate Penalty Set The Stage For Repeal Of The ACA

As part of a successful attempt to overhaul U.S. tax law aimed at energizing the economy, Republicans were able to zero out the individual mandate penalty in 2017. Once that happened, they insisted that a mandate stripped of its penalty for not purchasing health insurance meant the provision no longer was enforceable and could not be considered as being constitutional. Because the mandate is viewed as being such an essential component of the Affordable Care Act, eliminating it led to a claim that the entire law now should be struck down. A federal district court in Texas subsequently declared the ACA invalid in December 2018.

Twenty-one Democratic attorneys general and the House of Representatives then appealed this ruling to to the Fifth Circuit. That court partially affirmed the district court in 2019 in a 2–1 decision, agreeing that the mandate absent a penalty is unconstitutional. Significantly, this narrow majority ruling did not include what should be done with the ACA as a whole. Instead, the case was remanded back to the Texas district court for a more complete severability analysis. A main issue awaiting resolution is whether the mandate can be severed from the ACA, leaving the rest of the law to continue to be constitutional. Meanwhile, the Democratic attorneys general have appealed the ruling by the Fifth Circuit to the U.S. Supreme Court. Whether it will accept the case and deal with it in 2020 is unknown at this juncture.

PCORI Remains In Effect While Some ACA Taxes Are Repealed

The Patient-Centered Outcomes Research Institute (PCORI) was established by the ACA to promote comparative effectiveness research to assist patients, clinicians, purchasers, and policymakers in making informed health decisions. Although it enjoyed widespread support from the time of inception, detractors viewed it as a politically-driven program with attendant dangers associated with central planning. During 2019, there was some opposition to reauthorizing PCORI. Instead, the Institute enjoyed bipartisan support and its funding was reauthorized for 10 years as part of appropriations legislation described on page three of this issue of the newsletter.

That same appropriations package affected the ACA in other important ways. Members of Congress fully repealed the health insurance tax beginning in 2021, along with the so-called Cadillac tax on beneficiaries who have expensive insurance policies, and the medical device tax beginning in 2020. Repeal of the medical device tax always enjoyed bipartisan support because many states have companies affected by it. A potential downside is that these taxes were intended to cover the costs of expanding health insurance coverage under the law. It is estimated that repealing them will result in the loss of approximately $400 billion in revenue over the next ten years.

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More Articles from March 2020 TRENDS

SOME REFLECTIONS ON A PANDEMIC

PRESIDENT’S CORNER

RISING TO THE OCCASION

HEALTH REFORM DEVELOPMENTS

DEVELOPMENTS IN HIGHER EDUCATION

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

TEETH, EARLY-LIFE ADVERSITY, AND MENTAL HEALTH RISK