DEVELOPMENTS IN HIGHER EDUCATION

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

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

ASAHP And Third-Party Servicers and Institutions

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

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

HEALTH REFORM DEVELOPMENTS

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

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

Growth In Health Care Costs

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

The Risk Of Losing Health Insurance

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

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

NECESSITY OF A DEBT LIMIT INCREASE

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

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

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

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

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

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

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

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

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

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

DATA UNDERGIRD HEALTH POLICY FORMATION

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

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

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

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

PREPARING THE FEDERAL FY 2024 BUDGET

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

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

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

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

DEVELOPMENTS IN HIGHER EDUCATION

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

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

Public Hearings On Future Rulemaking Sessions

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

Student Loan Forgiveness

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

QUICK STAT (SHORT, TIMELY, AND TOPICAL

Maternal Mortality Rates In The United States: 2021

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

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

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

HEALTH TECHNOLOGY CORNER 

Breast Cancer Prevention And Screening Recommendations Provided By ChatGPT

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

Gene Editing To Prevent Ventricular Arrhythmias

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

HEALTH REFORM DEVELOPMENTS

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

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

Growth In Health Care Costs

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

The Risk Of Losing Health Insurance

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

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

TECHNOLOGY AND HEALTH CARE

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

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

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

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

THE ROLE OF EMPATHY IN QUALITY HEALTH CARE

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

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

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

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

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

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Emergency Department Visits Related To Mental Health Disorders

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

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

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

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Inhalable Hydrogel Protects Lungs From SARS-Cov-2

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

Technological Solutions To Loneliness—Are They Enough?

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

DEVELOPMENTS IN HIGHER EDUCATION

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

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

American College President Study

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

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

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

Resources On Equal Athletic Opportunities Under Title IX

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

HEALTH REFORM DEVELOPMENTS

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

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

Consumer Adoption Of Digital Health

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

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

Protecting Beneficiaries From “Junk” Health Plan Coverage

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

AVOIDING THE THIRD RAIL

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

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

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

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

ChatGPT AND A LITTLE TINK

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

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

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

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

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

CLIMATE CHANGE, INSECTS, AND HUMAN HEALTH

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

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

URBAN-RURAL DISPARITIES IN DEATHS OF DESPAIR

Although improvements in socioeconomic conditions and medical and technologic advancements contribute to reduced mortality rates over the past century, health disparities across various dimensions (e.g., race/ethnicity, gender, geographic location, and age) are becoming larger than ever in the U.S. As discussed in a paper in the February 2023 issue of the American Journal of Preventive Medicine, recent studies indicate increasing geographic inequalities in life expectancy. Regional variation in health outcomes is explained by differences in community-level factors, such as residential location, access to health care, access to healthy food, and proportion of college graduates. Health disparities can arise or be exacerbated when there is unequal access to these opportunities or resources. A dramatic increase in mortality occurs because of drug overdoses, suicide, and alcohol poisoning, referred to as deaths of despair or stress-related conditions (SRCs). A rise in SRC (2000-2015) first was reported among the non-Hispanic (NH) middle-aged White population in rural areas across the U.S.  

Midlife death rates also rose significantly between 1999 and 2016 among people of color that was driven primarily by drug, alcohol, and suicide deaths, but also because of increases in dozens of organ ailments, such as hypertensive heart disease and liver cancer. In general, rural areas are likely to have fewer socioeconomic resources than urban areas because of their physical location and lack of material and human resources. Separation from others who may provide social support also could exacerbate mental health problems and thus increase the risk of drug, alcohol, and suicide mortality. A study described in the aforementioned paper indicates that SRC mortality rates from 2004 to 2016 were not distributed randomly across the contiguous counties in the U.S. Findings suggest that educational attainment, disability status, access to health care, and contextual conditions can serve as measures to develop more effective prevention and intervention programs to target specific localities and tackle the deaths of despair epidemic. 

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Levels & Trends In Child Mortality 

Child survival is a critical marker of a thriving society. In 2021, there were an estimated five million deaths of children under age five. Sadly, this devastating loss of life was mostly preventable with widespread and effective interventions like improved care around the time of birth, vaccination, nutritional supplementation and water and sanitation programs. Without urgent action to reduce under-five mortality, more than 50 countries will not meet the underfive mortality target by 2030 and more than 60 countries will miss the neonatal mortality target. A new report by representatives from UNICEF, the World Health Organization, the World Bank, and the U.N. Department of Economic and Social Affairs indicates countries can take steps to further child mortality further, such as: Increase investment in primary health care; Scale up prevention and treatment of the leading causes of child mortality, such as newborn complications, pneumonia, diarrhea, malaria, and noncommunicable diseases; Provide sufficient food; Ensure water, sanitation, and hygiene in health facilities; and Establish peace and security. The report can be obtained here.

Race, Ethnicity, And The Design Of State Grant Aid Programs 

Most states use grant programs to lower the prices individual college students pay for their education. Unlike overall reductions in tuition prices for public institutions, these grant policies allow some students to pay less than others. The programs’ policy design and eligibility requirements vary by state and even across sectors. Some state grant aid, based on factors other than financial need, is distributed to students based on high school grades or test scores, intended courses of study, parental occupation, or other characteristics. According to a new report from the Urban Institute, this aid usually aims to reward achievement, to induce talented students to stay in state for college, to encourage students to prepare for occupations in high demand, or to acknowledge the challenges students in specific circumstances face. Need-based aid programs direct funds toward students for whom paying for college is difficult because of financial circumstances. These policies are rooted in both equity and efficiency goals. There is broad consensus that it is unfair to deny college access to potential students because of their inability to pay. Providing sufficient financial support to enable all admitted students to enroll in and succeed at an institution increases labor force productivity and reduces the need for publicly funded social supports. The report can be obtained here.

The Demographic Outlook: 2023 To 2053 

The size of the U.S. population, as well as its age and sex composition, affects the economy and the federal budget. For example, the size of the population ages 25 to 54 affects the number of individuals employed. Likewise, the size of the population age 65 or older affects the number of beneficiaries of federal programs, such as Social Security and Medicare. The Congressional Budget Office (CBO) in a new report describes its population projections, which underlie the agency’s baseline budget projections and economic forecast that will be published later this year. According to CBO projections, the Social Security area population, the relevant population for calculating Social Security payroll taxes and benefits and the measure of population used in this report, increases from 336 million individuals in 2023 to 373 million in 2053. As growth of the population age 65 or older outpaces growth of younger age groups, the population is projected to continue to become older and larger (by 0.8% in 2052, the final year of the projections that CBO released last year) and to grow slightly faster, on average, in this year’s projections, for two main reasons. First, net immigration is projected to be higher and second, mortality rates for the group age 65 or older are projected to be lower over the first two decades of the projection period. The decline stems from fewer deaths in 2022 due to COVID-19 infections than CBO previously projected. The report can be obtained here.

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Reasons For Receiving Or Not Receiving Bivalent COVID-19 Booster Vaccinations

Bivalent COVID-19 booster vaccines, developed to protect against both ancestral and Omicron BA.4/BA.5 variants, are recommended to increase protection against SARS-CoV-2 infection and severe disease. Relatively few eligible U.S. adults have received a bivalent booster dose, however, and reasons for low coverage are unclear. As indicated in the January 20, 2023 Morbidity and Mortality Weekly Report, an opt-in Internet survey of 1,200 COVID-19–vaccinated U.S. adults was conducted to assess reasons for receiving or not receiving a bivalent booster dose. The most common reasons cited for not receiving the bivalent booster dose were lack of awareness of eligibility for vaccination (23.2%) or of vaccine availability (19.3%), and perceived immunity against infection (18.9%). Participants who still had not received the booster dose most commonly reported being too busy to be vaccinated (35.6%). To help increase bivalent coverage, officials should use evidence-based strategies to convey information.  

Mortality In The United States, 2021

A new Data Brief (No. 456--December 2022) from the National Center for Health Statistics (NCHS) presents final 2021 U.S. mortality data on deaths and death rates by demographic and medical characteristics. Among the findings are the following: Life expectancy for the U.S. population in 2021 was 76.4 years, a decrease of 0.6 year from 2020. The age-adjusted death rate increased by 5.3% from 835.4 deaths per 100,000 standard population in 2020 to 879.7 in 2021. Age-specific death rates increased from 2020 to 2021 for each age group one year and older. Nine of the 10 leading causes of death in 2021 remained the same as in 2020. Heart disease, cancer, and COVID-19 remained the top three leading causes. The infant mortality rate was 543.6 infant deaths per 100,000 live births in 2021. The change in infant mortality from 2020 was not statistically significant. 

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Passive Monitoring By Smart Toilets For Precision Health 

Precision health is an approach to prevent, diagnose, and monitor disease using data gleaned from an individual’s biological information. Passive monitoring in a smart home setting, where appliances and devices are connected and controlled automatically, may provide such information. As described in the February 1, 2023 issue of Science Translational Medicine, of the possible locations in a smart home, the bathroom, and more specifically the toilet, is particularly well suited for such passive sensors. A “smart toilet” not only can monitor standard health characteristics, including temperature, heart rate, and oxygenation through sensors in the toilet seat, but also can collect biological samples (i.e., urine and stool) that contain useful health information. Yet, a reluctance to discuss excreta openly hampers the development and acceptance of smart toilets, which hold the potential to integrate urine and stool analyses seamlessly as part of routine toileting events and to serve as a gateway to the “digitalization” of health care in the home. 

Use Of Peptide 3D-Printing Inks To Advance Regenerative Medicine

Is it possible to build complex structures for housing cells using a material as soft as Jello? Scientists at Rice University believe that 3D printing represents a primary fabrication strategy used in biomedical research as recent efforts have focused on the 3D printing of hydrogels to create structures that better replicate the mechanical properties of biological tissues. As described in a study published on January 4, 2023 in the journal Advance Materials, these investigators envision that eventually the goal is to print structures with cells and grow mature tissue in a petri dish. These tissues then can be transplanted to treat injuries, or used to learn about how an illness works and to test drug candidates. There have been other attempts to 3D-print using other self-assembling peptides, but this effort is the first time that any self-assembling peptide system has been used to 3D-print such complex structures successfully. The structures were printed with either positively charged or negatively charged multidomain peptides.