APPROPRIATIONS RICORSO

Each year, this newsletter serves as a vehicle for describing actions by Congress to appropriate funds that enable the federal government to continue its operations. A movie released in 1993 called “Groundhog Day” is about a television weather reporter who awakes each day and relives it repeatedly while he is in the town of Punxsutawney, PA to film a report about annual Groundhog Day festivities. A proposition is advanced that the appropriations cycle each fiscal year on Capitol Hill is somewhat reminiscent of that same situation.

Fiscal year 2022 began on October 1, 2021 with no permanent funding in place for the next 12 months. Short-term remedies had to be devised in the form of one or more continuing resolutions (CRs). The most recent one expired on February 18, 2022. Legislators had two choices. The most desirable option would be to pass an omnibus bill that encompass 12 different categories of spending. Otherwise, another short-term CR is needed to prevent the government from shutting down. A new CR is in effect until March 11, 2022.

A disadvantage of functioning under a CR is that departments and agencies must operate with last year’s funding levels. An inability to know how much money Congress eventually will provide for a wide assortment of programs means that long-term budget planning is upended. It also remains unclear whether new initiatives either can or should be set in motion. Another serious drawback affects government staffing levels because of the uncertainty of not knowing whether positions will continue to be funded. The Health Resources and Services Administration (HRSA) within the U.S. Public Health Services is an example of an agency influenced negatively by the prevailing uncertainty. Important programs involving community health centers for the delivery of needed services and health workforce training are two of many entities to benefit immensely by having clearer funding signposts in efforts to go forward effectively.

Giambattista Vico (1668-1744) was the author of La Scienza Nuova, a book that he wrote to decipher the history, mythology, and laws of the ancient world. His conception of history is that it unfolds in four stages: theocratic, aristocratic, democratic, and chaotic. In the last phase, everything falls apart, producing a ricorso that results in a return to the theocratic phase where the cycle begins all over again.

Perhaps a way of viewing the annual funding cycle on Capitol Hill might be to consider it as occurring in the following stages:

Dread—Funding finally was approved for this year. Is it really time to begin once again?
Conflict—Why cannot colleagues on the other side of the aisle simply agree with us this time?
Anxiety—Will an omnibus bill ever be passed before the current fiscal year ends?
Satiety—We did it.

Lastly, related to determining if passage of omnibus legislation is achievable, the issue of parity tends to arise every year. If money for social programs is going to be increased, shouldn’t funding for military purposes be increased equally? The same quagmire holds true vice versa.

DUELING IHD “SKIN” NARRATIVES

The genesis of the Framingham heart study in 1948 and the onset of the great era of cardiovascular core risk factor identification (e.g., high lipid levels) are credited with a precipitous decline in ischemic heart disease (IHD) mortality. Rather than lauding this triumph, some epidemiologists have mounted a substantial critique of “risk-factor” epidemiology in IHD, notwithstanding its documented public health value. This critique arises from quite different directions as described in the January 2022 issue of the journal Epidemiology.

Proponents of the social determinants of health argue that it is necessary to move far “above the skin” by examining larger social forces that give rise to the biologic markers conventional epidemiology has treated as causal factors in IHD. Conversely, supporters of the human genome project advocate probing yet further “beneath the skin” to demonstrate that the massive investment in genome-wide association studies and the coalescence of these findings into polygenic scores will open up new avenues for prevention. The two positions to some extent reflect the contrast between the reductionism attractive to molecular biologists and the holism to which social scientists are drawn.

The debate is enriched in the Epidemiology issue by inclusion of a study that brings together genetic and sociodemographic antecedents, providing a welcome attempt at integrating risk factors operating across different levels of organization. Sophisticated mathematical and statistical tools used in the study are indifferent to preconceived causal structures and they have the additional benefit of helping to constrain the prejudices of investigators. The commonality linking the two schools of thought represented is not often recognized. Both argue that it is a mistake to see conventional cardiovascular risk factors as causes. Both agree that they are mere biologic intermediaries determined by factors operating long before they are evident, whether those factors can be social forces or genetic differences.

Both schools also argue that it is necessary to go beyond conventional thinking about cardiovascular risk factors to understand fully the causes of IHD. As has often been noted, causality is not a straight line, but a messy matrix of interacting and intersecting factors operating at different times and at different levels. This consideration especially is true for IHD, which has no singular cause. Although this nexus frequently has been described as a web of causation, that metaphor does not do full justice to the complexity of influences operating on several levels.

Another paper appearing in the January 2022 issue of the journal Nature Genetics complements what is known about cardiovascular disease. Efforts to elucidate causal mechanisms, including large-scale sequencing studies, have resulted in thousands of genes being associated with cardiovascular and cardiometabolic diseases with varying degrees of evidence. The traditional reductionist paradigm, i.e., one disease–one target–one drug, or, if need be, a combination thereof, is insufficient to provide mechanistic explanations and enable actionable subtyping or endotyping of diseases for precision medicine.

PATIENT SATISFACTION AND EXPERIENCE WITH TELEMEDICINE

Telemedicine, a potentially disruptive innovation, has emerged as an indispensable pathway to provide continued health care services and improvise public health outcomes during the COVID-19 pandemic. Following the global appearance of the coronavirus, health care providers began postponing several routines, elective care, and outpatient services due to extensive deployment of medical resources in the treatment of patients and to decrease the risk of virus transmission. Another consequence is that face-to-face consultations were disrupted because of hesitation in consulting physicians in the hospital setting. As discussed in an article about patients’ satisfaction and experience with telemedicine that was published in the December 2021 issue of the journal Telemedicine and e-Health, partial or complete disruption of health care services for non-COVID diseases in many countries involved hypertension; diabetes and diabetes-related complications; cancer screening and treatment; cardiovascular emergencies; and rehabilitation. The most common reasons cited for disruption of health care services were lack of health workers’ availability, diversion of health workers to COVID-19 management, cancellation of planned treatments, and risk of virus transmission during on-site patient visits.

Telemedicine became a useful alternative towards streamlined response to the pandemic. Per the WHO, this modality is defined as the delivery of health care services by health care professionals using technology entailing the exchange of medical information for the diagnosis, treatment, and prevention of diseases and injuries. It includes synchronous mode (e.g., video visits, audio visits), asynchronous mode (e.g., emails), and remote monitoring of patients. Researchers sought to identify relevant studies published between December 2019 and August 2020 that highlighted patients’ satisfaction and experience with the use of telemedicine during the pandemic. The findings based upon 48,144 surveyed patients and 146 providers in 12 different countries revealed high satisfaction with virtual encounters across a spectrum of diseases. Telemedicine was found satisfactory on various outcome measures, such as addressing patients’ concerns, communication with health care providers, usefulness, and reliability. Most common advantages were time saved due to lesser traveling and waiting time, better accessibility, convenience, and cost efficiency. Age and sex did not have any significant impacts on satisfaction levels. Physicians and patients both showed a strong preference for continued usage and agreed upon telemedicine's potential to complement the regular health care services even after the pandemic.

THE CRISPR CHILDREN THREE YEARS LATER

The September 2021 issue of the newsletter TRENDS, featured an article on the topic of biological technology prospects, with an emphasis on CRISPR (clustered regularly interspaced short palindromic repeats). Designed as a tool for editing human genes, since it began to attract attention in the media in 2012, ethical discussions about the legal status of such editing have been generated. Shocking reactions occurred around the world in November 2018 when it was learned that two babies had been born in China with DNA edited while they were embryos, a development in genetics as dramatic as the 1996 cloning of Dolly the sheep. Presently, the fate of these three-year-old toddlers remains shrouded in secrecy amid swirls of rumors. Many individuals who were contacted for an article published in the December 2021 issue of the journal Nature Biotechnology refused to speak about the children, who purportedly are healthy. Some respondents agreed to do so only on condition of anonymity.

The original goal of these heritable gene edits was to generate HIV-resistance by introducing germline mutations. The effort was roundly criticized by researchers and ethicists. Thus far, the children themselves have not received much attention. They are considered both celebrities and victims, with their health and well-being a closely held secret. Initially, it was envisioned that development and health would be monitored until their 18th birthdays. Upon reaching adulthood, the girls would be asked to re-consent in order for the testing to continue. An anonymous source indicates that the babies reportedly had medical checkups at birth, at one and six months of age, and at one year. Establishing how the edits to their genomes will translate into health benefits or risks later in life is challenging. Because of widely differing viewpoints on the potential impact of these edits on their physical and mental health, it is difficult to know what lies ahead for the girls.

OBTAINABLE RESOURCES

U.S. Healthcare Quality And Disparities
The Agency for Healthcare Research and Quality (AHRQ) has released its 2021 National Healthcare Quality and Disparities Report, which details the state of healthcare quality and disparities in the United States. Additionally, improvements in HIV and colon cancer care, nursing home care, and medication prescribing to older adults are identified. The report also indicates that more work needs to be performed to address disparities in important areas. Among the findings are the following:

• The numbers of individuals covered by health insurance and those who have a usual source of healthcare have increased significantly.

• Personal spending on health insurance and healthcare services decreased for those under age 65 with public insurance and increased for holders of private insurance coverage.

• Access to dental care and oral healthcare services remains low and has not substantially improved, particularly for individuals who have low income or who live in rural areas.

• A multiyear rise in opioid-related hospitalizations had been tapering off prior to the COVID-19 pandemic, but the opioid crisis has worsened markedly since then. Suicide death rates were rising in all groups for more than a decade before the pandemic. Since then, suicide deaths have decreased in White populations, but continue to rise in racial and ethnic minority populations. Limited access to substance abuse and mental health treatment may have contributed to these crises.

• Although Black, Hispanic, American Indian, and Alaska Native communities have experienced substantial improvements in healthcare quality, significant disparities in all domains of quality persist. Even when rates of improvement in quality exceeded those experienced by White Americans, the improvements have not been enough to eliminate disparities. The report can be obtained here.

State Trends In Employer Premiums And Deductibles, 2010–2020
Employer health insurance coverage has been relatively stable in recent years, falling only slightly during the COVID-19 pandemic. That news for the most part is encouraging, but costs for this coverage are on the rise. Unfortunately, the increase is constituting a larger share of workers’ paychecks. A new Commonwealth Fund report analyzing trends in employer plan premiums and deductibles across all states finds that over the last decade, incomes have not kept pace with health insurance costs, which are driven largely by high prices for drugs and health care services. In 37 states, premium contributions and deductibles together consumed as much as 10% or more of median household income in 2020, up from just 10 states a decade earlier. For single and family insurance policies, the average total cost of premiums and potential deductible spending ranged from a low of $6,528 in Hawaii to a high of more than $9,000 in five states, including Florida and Texas. The report can be obtained here.

Medicare Beneficiaries’ Use Of Telehealth In 2020
A new report from the U.S. Department of Health and Human Services (HHS) found that massive increases in the use of telehealth helped maintain some health care access during the COVID-19 pandemic, with specialists like behavioral health providers seeing the highest telehealth utilization relative to other providers. The report, which was produced by researchers in the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) analyzes Medicare fee for service (FFS) data in 2019 and 2020 and also highlights that telehealth services were accessed more in urban areas than rural communities. Black Medicare beneficiaries were less likely than White beneficiaries to use telehealth. The share of Medicare visits conducted through telehealth in 2020 increased 63-fold, from approximately 840,000 in 2019 to 52.7 million. States with the highest use of telehealth in 2020 included Massachusetts, Vermont, Rhode Island, New Hampshire and Connecticut. States with the lowest use of telehealth in 2020 included Tennessee, Nebraska, Kansas, North Dakota, and Wyoming. The report can be obtained here.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

COVID Impact On Employment Status Of LGBTQ+ Individuals
COVID-19 has had a disproportionate impact on employment for minority population sub-groups resulting in higher unemployment rates and health care concerns, according to a study from Rutgers University that was published on November 13, 2021 in the journal Sexuality Research and Social Policy. The aim of the investigation was to identify the specific effects of job loss trends on LGBTQ+ individuals in the U.S. The results indicate that employment of members of this group has been undermined by COVID-19, but as with all population segments, those individuals with multiple minority identities, such as Black or HIV+ and LGBTQ+, have been affected most severely. This study highlights the need for national data collection on sexual orientation and gender identity for unemployment as well as the need for substantive policies, such as expanding unemployment to assist in the economic recovery for population groups most affected by COVID-19, along with the Equality Act to offer further workplace protections.

Trends In Adolescent Cannabis-Related Hospitalizations By State Legalization Laws, 2008-2019
The impact of cannabis legalization on adolescent cannabis-related hospitalizations remains unknown. An investigation described in the December 2021 issue of the Journal of Adolescent Health sought to assess whether state cannabis legalization is associated with adolescent cannabis-related hospitalizations. The study involved states with no legal use to medical cannabis laws (MCLs) and states with MCLs to nonmedical (>21 years old) cannabis laws (NMCLs). Of 1,898,432 adolescent hospitalizations in 18 states and Washington, DC, there were 37,562 (2%) hospitalizations with a cannabis-related diagnosis, with 8,457 (23%) in states with no legal use, 20,444 (54%) in MCL states, and 8,661 (23%) in NMCL states. Among the conclusions reached, cannabis-related adolescent hospitalizations at children’s hospitals are increasing, with a disproportionate increase post-legalization in states with NMCLs. Interventions are warranted to increase cannabis use identification and treatment among at-risk adolescents in the hospital-based setting.

HEALTH TECHNOLOGY CORNER

Factors Involving 10-Year Declines in Physical Health and Function Among Women During Midlife
Women in midlife often develop chronic conditions and experience declines in physical health and function. Identifying factors associated with declines in physical health and function among these women may allow for targeted interventions. As reported in a cohort study described on January 10, 2011 in the journal JAMA Network Open, the objective by investigators at Brigham and Women’s Hospital was to examine factors associated with clinically important 10-year declines in the physical component summary score (PCS) of the Short Form 36 (SF-36), a widely used patient-reported outcome measure, in women in midlife. The findings reveal that clinically important declines in women’s physical health and function were relatively common between ages 55 and 65 years. Several variables associated with these declines were identified as potentially useful components in a clinical score identifying women at increased risk of physical health and functional declines.

How Skin Cells Form A First Line Of Defense Against Cancer
A study published on January 11, 2011 in the journal Cell Reports reveals important insights into the molecular mechanisms that underpin the body’s natural defenses against the development of skin cancer. The findings offer new clues into the behavior of skin cancer at the cellular level, paving the way for potential new therapeutic targets to treat the disease. The investigation by researchers at the Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology in Spain, indicates that the protein CSDE1 coordinates a complex chain of events that enable senescence in skin cells. The senescent cells act as a firewall against cancer, suppressing the formation of tumors. The findings are surprising because CSDE1 previously has been linked to driving the formation of cancers. The study is one of the few to examine the role of RNA-binding proteins in establishing cell senescence, which is an important new frontier in cancer research.

DEVELOPMENTS IN HIGHER EDUCATION

The year 2022 began with the number of Covid-19 case counts mounting steadily due to the more transmissible Omicron variant. Some leaders of higher education institutions have responded by either choosing to begin the spring semester online or delay the date when faculty, staff, and students will be allowed to return to campus. Administrators in school districts around the nation have had to make similar decisions for elementary and secondary institutions. Apart from risks associated with experiencing physical symptoms of the disease, adverse mental health effects related to the coronavirus also are considered to be quite worrisome.

The Biden Administration has played an active role in trying to keep schools safely open for full-time, in-person instruction. These efforts have resulted in 96% of schools opening on an in-person basis in January 2022, up from 46% of schools in January 2021. New initiatives will lead to an increase in the number of COVID-19 tests available to schools by 10 million per month. During the past year, federal funding provided to states and school districts across the nation, including $130 billion in the Elementary and Secondary School Emergency Relief is directed toward safely reopening schools and addressing students’ academic and mental health needs. Another $10 billion in the Epidemiology and Laboratory Capacity (ELC) cooperative agreement is being used to support COVID-19 testing for students and staff.

Unified Agenda And Regulatory Plan
The Fall 2021 Unified Agenda and Regulatory Plan was published on December 10, 2021. The U.S. Department of Education anticipates issuing the Title IX notice of proposed rulemaking by April 2022, a month earlier than the May 2022 date listed in the Spring 2021 Unified Agenda. The Department is deeply committed to: ensuring that schools are providing students with educational environments free from discrimination in the form of sexual harassment; ensuring that schools have grievance procedures that provide for the fair, prompt, and equitable resolution of reports of sexual harassment and other sex discrimination; and addressing discrimination based on sex, including sexual orientation and gender identity, in educational environments. In line with those commitments, the Department also has expressed its intent to propose amendments to its regulations implementing Title IX to address these issues.

Student Loan Pause Extended
The Department on December 22, 2021 announced a 90-day extension of the pause on student loan repayment, interest, and collections through May 1, 2022. The extension will allow the Administration to assess the impacts of the Omicron variant on student borrowers and provide additional time for borrowers to plan for the resumption of payments and reduce the risk of delinquency and defaults after restart. The pause will help 41 million borrowers save $5 billion per month. This action is part of a series of steps the Biden Administration has taken to support students and borrowers, make higher education more affordable, and improve student loan servicing, including providing nearly $13 billion in targeted loan relief to over 640,000 borrowers. Specific examples include providing $7.0 billion in relief for 401,000 borrowers who have a total and permanent disability, and helping 30,000 small business owners with student loans seeking help from the Paycheck Protection Program.

Negotiated Rule-Making Committee Expected To Address Unresolved Issues
As the year 2022 unfolds, it is likely that efforts will be undertaken by the Department’s Negotiated Rule-Making Committee to reach agreement on some contentious issues. Prominent examples are:

• How the Education Department processes and adjudicates claims for loan forgiveness by borrowers who are defrauded by their college as well as the circumstances in which borrowers are entitled to loan forgiveness when their college suddenly closes.

• How to structure the administration’s new income-driven repayment plan and how to expand the Public Service Loan Forgiveness program.

SEASONAL UNCERTAINTIES

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

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

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

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

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

TECHNOLOGICAL IMPACTS ON HEALTH

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

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

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

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

RESIDENTIAL DISORDER AND BIOLOGICAL MARKERS OF AGING

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

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

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

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

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

OBTAINABLE RESOURCES

Annual Report To The Nation On The Status Of Cancer

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

Prison And Jail Reentry And Health

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

2020 National Survey Of Drug Use And Health

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

DEVELOPMENTS IN HIGHER EDUCATION

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

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

Impact Burden Of And Solutions For FAFSA Verification

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

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

CBO Cost Estimates For The Build Back Better Act

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

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

ASTROBIOLOGY AND INCARCERATION

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

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

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

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

NEW INSIGHTS ON THE DETERMINANTS OF HEALTH TECHNOLOGIES USAGE

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

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

MULTIMORBIDITY FROM THE PERSPECTIVE OF COMPLEXITY SCIENCE

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

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

OBTAINABLE RESOURCES

Long-Term Services And Supports Needed By Retirees

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

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

Journals Of Gerontology Scientific Articles On COVID-19

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

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

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

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

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

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Emergency Department Visits Involving Dental Conditions, 2018

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

Health Care Spending For Working Americans

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

HEALTH TECHNOLOGY CORNER

Near-Infrared Fluorogenic Spray For Rapid Tumor Sensing

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

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

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

DEVELOPMENTS IN HIGHER EDUCATION

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

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

Meeting The Costs Associated With Participating In Higher Education

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

Quality Of Education Below The College Level

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

HEALTH REFORM DEVELOPMENTS

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

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

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

The U.S. Census Bureau announced on September 14, 2021 that median household income was $67,521 in 2020, a decrease of 2.9% from the 2019 median of $69,560. The drop is the first statistically significant decline in median household income since 2011. The total number of individuals with earnings decreased by about 3.0 million, while the number of full-time, year-round workers decreased by approximately 13.7 million. The official poverty rate in 2020 was 11.4%, up 1.0 percentage point from 2019, which is the first increase in poverty after five consecutive annual declines. In 2020, there were 37.2 million individuals in poverty, approximately 3.3 million more than in 2019. Private health insurance coverage continued to be more prevalent than public coverage, at 66.5% and 34.8%, respectively. Some beneficiaries may have more than one type of coverage during the calendar year. Of the subtypes of health insurance, employment-based insurance was the most common variety, covering 54.4% of the population for some or all of the calendar year.

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

U.S. Health Insurance Market Competition

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